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Improving the specificity of drug-drug interaction alerts: can it be done?

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Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.

Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

Annual Perspective: Topics in Medication Safety

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March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study.

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Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22:2553-2558.e1.

Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.

Impact of clinical decision support therapeutic interchanges on hospital discharge medication omissions and duplications.

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Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78:s88-s94.

Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

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Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.

Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.

When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication

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October 28, 2020

A 58-year-old female receiving treatment for transformed lymphoma was admitted to the intensive care unit (ICU) with E. coli bacteremia and colitis secondary to neutropenia, and ongoing hiccups lasting more than 48 hours. She was prescribed thioridazine 10 mg twice daily for the hiccups and received four doses without resolution; the dose was then increased to 15 mg and again to 25 mg without resolution.

Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.

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Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.

Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use.

Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without.

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Erickson SR, Kamdar N, Wu C-H. Am J Intellect Dev Disabil. 2019;125:37-48.

Prior research has found that children with intellectual or developmental disabilities (IDD) may experience poor quality care and are at risk for adverse events, but less is known about risk among adults with IDD. Using data from a nationally representative database, the authors compared hospitalizations due to adverse medication events among adults with IDD compared with the general adult population and found that adults with IDD were at a significantly greater risk of having a hospital admission due to an adverse event (odds ratio, 1.28).

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation

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Parker H, Farrell O, Bethune R, et al. Br J Clin Pharmacol. 2019;85:2405-2413.

Despite process changes and availability of new technologies, prescribing errors (one type of medication administration errors) remain a serious safety problem. This article describes a single-site pharmacist-led intervention that involved doctors-in-training (residents) reviewing video footage of their patient visits with a pharmacist. The feedback intervention resulted in a significant reduction in prescribing errors and was found acceptable and feasible by participants.

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