Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 4028

This WebM&M features two cases involving patients undergoing surgical procedures who received perioperative opioid analgesics to aid in pain and sedation efforts and who experienced adverse events due to opioid stacking. The commentary provides evidence-based suggestions for optimal management of patients who are administered opioid therapy, including standardized sedation assessment, advanced patient monitoring strategies, appropriate use of naloxone, and non-opioid pain management strategies.

Chiel L, Freiman E, Yarahuan J, et al. Hosp Pediatr. 2021;12(1):e35-e38.
Medical residents write patient care orders overnight that are often not reviewed by attending physicians until the next morning. This study used the hospital’s data warehouse and retrospective chart review to examine 5927 orders over a 12-month period, 538 were included in the analysis. Key reasons for order changes included medical decision making, patient trajectory, and medication errors. Authors suggest errors of omission may be an area to direct safety initiatives in the future.
Oura P. Prev Med Rep. 2021;24:101574.
Accurate measurement of adverse event rates is critical to patient safety improvement efforts. This study used 2018 mortality data and ICD-10-CM codes to characterize adverse event deaths in the United States compared to non-adverse event deaths. The author estimates that 0.16-1.13% of deaths are attributed to an adverse event. Procedure-related complications contributed to the majority of adverse event deaths. The risk of death due to adverse event was higher for younger patients and Black patients.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8(4):e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2021;Epub Dec 28.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Warner MA, Warner ME. Anesthesiology. 2021;135(6):963-974.
The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22(12):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.

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is February 11, 2022.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87(11):4150-4172.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12(1):37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163(1):83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19(6):521-526.
Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.1 Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.1,2

The STORM decision support system uses data extracted from VHA electronic medical records and predictive analytics to facilitate the identification of patients at high risk of experiencing overdose and suicide events. The STORM decision support system can also review risk factors for patients who are being considered for prescription opioid therapy. STORM prioritizes patients for monitoring and intervention according to their modeled risk and aids clinicians by displaying a patient’s risk factors and associated evidence-based risk mitigation interventions. Note that the target population does not include patients with OUD in medication-assisted treatment (MAT).

Many patients with OUD and/or in prescription opioid therapy have complex medical and psychosocial needs (e.g., painful conditions, mental health challenges), resulting in interactions with multiple care providers. To address the complexity of a patient’s case, STORM aims to provide a holistic intervention that includes multiple care providers and accounts for multiple parts of the patient’s history and medical profile.3 Under the STORM-based targeted prevention program, an interdisciplinary team of clinicians, including those with expertise in pain and behavioral health, conduct case reviews for patients identified to be at the highest risk of overdose and/or suicide and implement treatment changes or share recommendations with the patients‘ providers.

The VHA completed a three-year randomized program evaluation of the implementation of the national STORM-based targeted prevention program. Preliminary results indicate that mandating that very high-risk patients receive an interdisciplinary review was associated with a decrease in all-cause mortality among identified patients in the 127 days after identification by the decision support system.4

The STORM decision support system and targeted prevention program were developed and implemented in the context of relatively high rates of opioid prescribing to veterans and overall rising opioid-involved overdose mortality in the U.S. population. In the last 10 years, overdose deaths have more than doubled in the United States.5 As one response to the problem, the 2016 Comprehensive Addiction and Recovery Act requires the VHA to improve opioid therapy strategies and to ensure responsible prescribing practices. STORM is one of several VHA overdose prevention initiatives that include the distribution of naloxone, efforts to reduce opioid prescribing, and introduction of pain management clinical review and support teams.5

Institute for Safe Medication Practices. January 27-28, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.