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Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Schillig J, Kaatz S, Hudson M, et al. J Hosp Med. 2011;6:322-8.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Sentinel Event Alert. 2008;41:1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.
Gao H, McDonnell A, Harrison DA, et al. Intensive Care Med. 2007;33:667-79.
Rapid response teams are being widely implemented in hospitals worldwide. These teams are summoned to evaluate patients who meet specific clinical "triggers" (e.g., abnormal vital signs). This systematic review evaluated the ability of such triggers to accurately identify inpatients whose clinical condition is deteriorating. The false-negative rate of commonly used triggers was relatively high, meaning that a significant proportion of acutely unstable patients would not be identified by such criteria. This problem was noted in a prior negative study of rapid response teams. The authors recommend further research to determine the combination of triggers that most accurately identifies clinical instability.
Kramer JS, Hopkins PJ, Rosendale JC, et al. Am J Health-Syst Pharm. 2007;64:404-422.
The Joint Commission has mandated that all hospitals implement a system for medication reconciliation to ensure that patients' medications are not inappropriately discontinued or changed. This study reports on the implementation of a system in which pharmacists and nurses collaborated to complete electronic documentation of medication reconciliation. Patients were satisfied with the approach and reported improved understanding of their discharge medications. Prior research in this area has documented the effectiveness of pharmacists in the medication reconciliation process.
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
An unclear verbal order leads to administration of the wrong drug.