All Content

Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.

This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.

This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.

Clinical provider order entry (CPOE) and clinical decision support systems  (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.   

Bone marrow transplantation requires complex drug therapy management. This systematic review identified 11 studies reporting both medication prescription and administration errors, as well as issues such illegible writing, polypharmacy, absence of medication reconciliation, and lack of patient education. These errors resulted in a variety of adverse events.  The review identified several prevention measures that can be implemented at the provider-level or systems-level (e.g., computerized prescribing systems).

Prescribing errors are common and can result in patient harm. This review summarizes four key options to reduce prescribing errors: prescriber education, effective use of computerized alert systems at the clinical interface, use of tools and guidance to inform practice, and multidisciplinary teams that include pharmacists.

This study, conducted at a Brazilian hospital, found that the IHI Global Trigger Tool had relatively poor accuracy at identifying adverse drug events among hospitalized patients. The accuracy and reliability of trigger tools have been questioned in other studies.

This study used trigger tools to identify the incidence and risk factors for medication errors in a pediatric intensive care unit.

A multidisciplinary intervention significantly reduced the incidence of medication errors in an adult intensive care unit.

This study found that omission and administration errors were the most common types of medication errors in a pediatric oncology population.

Inadequate dosing of anticoagulant medications was common in the emergency department due to inaccurate estimation of body weight.

Pharmacy problems, including lack of medication availability and transcription problems, were the principal contributors to medication errors in this Brazilian study.

This study examined medication error rates before and after implementation of interventions targeted toward an improved safety culture. Investigators demonstrated a modest but significant reduction in error prevalence.

Periodic audit and feedback on prescribing errors resulted in near elimination of prescribing errors related to incorrect dosing or route of administration.

A high incidence of medication errors was documented in a neonatal intensive care unit in Brazil.

This cross-sectional study observed nursing staff prepare and administer intravenous medications. The authors report a low overall error rate with the most frequent types of errors associated with wrong dose and omission of dose.

This commentary discusses several individual and system factors that both cause and contribute to dispensing errors.

This retrospective study found that, in hospitalized cancer patients, length of stay and number of medications were risk factors for potential drug interactions.