Zheng WY, Lichtner V, Van Dort BA, et al. Res Soc Admin Pharm. 2021;17(5):832-841.
This systematic review sought to determine the impact of automated dispensing cabinets (ADCs), barcode medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) used by hospitals in reducing controlled substance medication errors in hospitals. Overall, only 4 studies (out of 16) focused directly on controlled medications. A variety of types of errors (e.g., log-in, data, entry, override) compromised patient safety. High-quality targeted research is urgently needed to evaluate the risks and benefits of medication-related technology.
Ruutiainen HK, Kallio MM, Kuitunen SK. Eur J Hosp Pharm. 2021;Epub Jan 17.
Automated drug dispensing systems can reduce medication dispensing and administration errors. However, this study found that medication automated dispensing cabinets ADCs)in one hospital frequently contained look-alike, sound-alike (LASA) medications, which may increase the risk for medication error.
Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.
Horsham, PA: Institute for Safe Medication Practices; 2020.
This updated report outlines 16 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2020 update includes new practices that are associated with opioids and automated dispensing cabinet overrides. ISMP is currently seeking insights as to the implementation of the current best practices. Survey responses are due by July 30, 2021.
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
Automated dispensing cabinets (ADCs) have been implemented in hospitals to improve drug administration safety, but with misuse, can cause patient harm. This newsletter article focuses on three primary ADC user-related problems and offers recommendations for reducing factors that minimize their safe use.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associated with their use still occur. This report provides comprehensive guidelines on the safe use of automated dispensing cabinets. Recommendations include improvement in areas such as stocking, labeling, and removal of expired medications.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.
ISMP Medication Safety Alert! Acute Care Edition. January 17, 2019;24.
This newsletter article reports on the findings of a government investigation into the death of a patient during a positron emission tomography scan. A neuromuscular blocking agent was mistakenly administered instead of an anti-anxiety medication with a similar name. The investigation determined various individual and system failures that contributed to the incident, such as misuse of automated dispensing cabinets, wrong picklist medication selection, workarounds of override protections, and lack of patient monitoring. Recommendations for preventing similar incidents include use of barcoding verification, automated dispensing cabinet stocking changes, and labeling improvements.
Campmans Z, van Rhijn A, Dull RM, et al. PloS one. 2018;13(5):e0197469.
Dispensing errors are a common source of preventable adverse events in community pharmacies. Dutch investigators evaluated the effectiveness of an electronic system in reducing drug name confusion among similar medications. Users found the system was helpful for preventing dispensing errors and did not feel it contributed substantially to alert fatigue.
Bledsoe S, Van Buskirk A, Falconer J, et al. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists. 2018;75:127-131.
Although medication errors are a common source of preventable harm across health care settings, hospitalized children are at especially increased risk. This study evaluated a pediatric hospital's barcode-assisted medication preparation technology for dispensing oral liquid medications. The technology enhanced safety, averting more than 3000 medication errors over a one-year period.
Workflow processes for compounded sterile preparation can affect patient safety. Discussing how pharmacies have increasingly implemented workflow management systems to automate compounded sterile solution processes, this newsletter article reviews challenges associated with these systems and recommends strategies to reduce risks.
Heron C. British journal of nursing (Mark Allen Publishing). 2017;26:S13-S16.
Smart pumps play an important role in preventing medication errors, but they can also introduce patient safety hazards. This commentary describes software that can be loaded on smart pumps to help manage dosing errors and how to successfully implement it.
Rostas SE. The Journal of perinatal & neonatal nursing. 2017;31:15-19.
Medication errors are common in the neonatal intensive care unit. This commentary outlines various strategies one teaching hospital has utilized to reduce risks of medication errors in this care setting, such as use of computerized provider order entry and smart pumps.
Drake E, Srinivas P, Trujillo T. Am J Health-Syst Pharm. 2016;73(14):1033-1035.
Automated dispensing cabinets have been adopted in hospitals to enhance medication safety. These drug dispensing systems enable override functions so that nurses can access medications without pharmacist verification to ensure timeliness, but this workaround requires a reliable process to reduce the potential for errors. This commentary discusses how one hospital designed an oversight process using computerized provider order entry to increase the safety of this practice.
Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73(12):887-893.
Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.
Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26(2):131-140.
Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.
Hospitalized with nonketotic hyperglycemia, a man was placed on IV insulin and his blood sugars improved. That evening, the patient was transferred to the ICU with chest pain and his IV insulin order was changed to sliding scale subcutaneous insulin. However, over the next several hours, the patient again developed hyperglycemia.
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