The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Schiff GD, Amato MG, Eguale T, et al. BMJ Qual Saf. 2015;24:264-71.
This study used a two-stage approach to analyze the effectiveness of computerized provider order entry (CPOE) at preventing medication errors in real-world settings. The investigators analyzed data from the MEDMARX database in order to identify the types of medication errors caused by computerized order entry. From these data, the researchers developed 21 examples of problematic orders and tested whether they could be entered in a range of commercial CPOE systems. The majority of orders were entered successfully and quickly, without the CPOE system generating any alerts or requiring clinicians to use only minor workarounds to enter the order. Even when the CPOE system did generate an alert, these could generally be overridden by clinicians without changing the order. The study findings mirror those of a prior simulation study and highlight the importance of real-world usability testing for health information technology. Although CPOE systems have been shown to reduce prescribing errors, this study's results indicate that the safety benefits of CPOE may not be achieved without careful implementation and ongoing evaluation.
Kripalani S, Roumie CL, Dalal AK, et al. Ann Intern Med. 2012;157:1-10.
Hospital discharge remains a particularly vulnerable time for adverse drug events, despite the use of medication reconciliation and other strategies to prevent medication errors at discharge. Previously, pharmacist involvement has also been shown to be beneficial in reducing medication errors, and even led to decreased readmissions in at least one study. However, in this randomized, controlled trial, approximately 50% of adult patients who received a robust pharmacist-driven intervention still experienced a clinically important medication error within one month following discharge for an episode of acute coronary syndrome or acute decompensated heart failure. The four-component intervention included pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. A case of a preventable readmission due to a medication error is discussed in this AHRQ WebM&M commentary.
Medication reconciliation was reinstated as a Joint Commission National Patient Safety Goal in 2011, with the goal of reducing adverse drug events (ADEs) due to inadvertent medication discrepancies. However, a lack of proven medication reconciliation strategies has resulted in frustrating experiences for many hospitals attempting to meet this requirement. This systematic review identified 26 studies of hospital-based medication reconciliation efforts, the majority of which relied on pharmacists or information technology–based interventions. Although pharmacist-led interventions and interventions focusing on high-risk patients were generally successful at reducing potential ADEs, the authors concluded that the overall literature base was insufficiently rigorous to draw firm conclusions about which strategies are both effective and generalizable.
Avery AJ, Rodgers S, Cantrill JA, et al. Lancet. 2012;379:1310-9.
Pharmacists continue to play a critical role in reducing medication errors. Past studies have focused on their impact in emergency departments and hospital settings, as well as their impact on the discharge process and specialized services. This study implemented a pharmacist-led information technology intervention (PINCER) composed of feedback and educational outreach to a randomized subset of 72 primary care practices in the United Kingdom. At 6 months following the intervention, patients in the PINCER group experienced substantially reduced frequency of clinically important prescription (e.g., beta blocker in a patient with asthma) and medication monitoring errors (e.g., ACE inhibitor in an elderly patient without assessing electrolytes). The authors suggest that their intervention can be of increasing value to other health systems that are moving towards computerized electronic health records. A past AHRQ WebM&M perspective discussed preparing pharmacists for the future in patient safety.
Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-73.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.
Strategies to prevent medication errors are an ongoing focus in patient safety. Computerized provider order entry, medication reconciliation, avoidance of drug–drug interactions, and bar-coded medication administration are a few areas generating significant attention. This review discusses an alternate approach to medication safety, focusing on prevention of prescribing unnecessary medications at the outset. The authors provide a set of principles that urge clinicians to: think beyond drugs, practice more strategic prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients for a shared agenda, and consider long-term impacts of medications prescribed. Each of these principles is discussed and sets the background for a recommendation to shift current paradigms in prescribing from "newer and more is better" to "fewer and more time tested is best."
Hamilton H, Gallagher P, Ryan C, et al. Arch Intern Med. 2011;171:1013-9.
Many medications, particularly sedatives and other drugs with significant side effects, are considered inappropriate for prescribing in elderly patients. However, the existing Beers criteria for appropriateness lack predictive power for adverse drug events. This prospective cohort study reports on the validation of the STOPP criteria, a novel list of medications considered inappropriate for elderly patients. Patients who received medications considered inappropriate by STOPP had a nearly two-fold increased odds of an adverse drug event during hospitalization, while the Beers criteria failed to predict medication errors. Given the recognized limitations of the Beers criteria, the STOPP criteria likely represent a superior method of identifying dangerous medications in geriatric patients.
Poon EG, Keohane CA, Yoon CS, et al. New Engl J Med. 2010;362:1698-1707.
Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.
Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010;126:14-21.
Computerized provider order entry (CPOE) has been enthusiastically endorsed as a means of preventing medication errors, and some studies have shown clinical benefits associated with its use. However, a growing body of literature demonstrates that CPOE implementation may have many unintended consequences affecting clinician workflow, and these issues may account for the mixed safety performance of CPOE. This study, conducted at an academic tertiary care hospital, found that overall inpatient mortality decreased after CPOE was launched, with an estimated 36 lives saved in the first 18 months after implementation. These findings counter an earlier, widely cited study in which mortality increased after CPOE installation, and point to the importance of careful attention to the implementation process to ensure that CPOE meets its potential.
Metzger J, Welebob E, Bates DW, et al. Health Aff (Millwood). 2010;29:655-663.
Computerized provider order entry (CPOE) has provided significant safety benefits in research studies, especially when combined with clinical decision support to prevent common prescribing errors. However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety of unintended consequences. This AHRQ-funded study used simulated patient records to evaluate the ability of eight commercial CPOE modules to prevent medication errors. The overall results were disappointing, as CPOE failed to prevent many medication errors—including fully half of potentially fatal errors, which are considered never events. The individual CPOE products varied significantly in their ability to detect potential errors. Some hospitals did achieve superior performance, which the authors ascribe to greater experience with CPOE and implementation of more advanced decision support tools. Another recent article found that reminders within CPOE systems resulted in only small improvements in adherence to recommended care processes. Taken together, these studies imply that CPOE implementation may not result in large immediate effects on safety and quality in typical practice settings.
Cohen V, Jellinek SP, Hatch A, et al. Am J Health Syst Pharm. 2009;66:1353-1361.
Prevention of medication errors in emergency departments is a growing focus of safety efforts, due in part to a National Patient Safety Goal targeting medication errors. Clinical pharmacists effectively prevent medication errors in the inpatient setting, but their role in the emergency department is less studied. This systematic review of 17 published studies characterizes roles played by emergency pharmacists, including medication reconciliation, error prevention, and a variety of other duties. Another study (not included in this review) found a significant reduction in medication errors after assigning pharmacists to review medication orders in the emergency department.
Walsh KE, Landrigan CP, Adams WG, et al. Pediatrics. 2008;121:e421-e427.
Studies of the effect of computerized physician order entry (CPOE) in pediatrics have reached conflicting results. This study evaluated the impact of a commercial CPOE system on medication errors over a 16-month time frame. Strengths of this study included use of a comprehensive error-finding method and a time-series analytical approach. Implementation of the CPOE system was associated with a modest reduction in "nonintercepted" serious medication errors (errors that were not detected, and thus affected the patient), but there was no overall decrease in injuries suffered due to adverse drug events. Notably, the rate of dosing errors—the most common type of pediatric drug error—did not decrease, despite specific features of the CPOE system designed to prevent such errors. The authors discuss their experience with the system and subsequent modifications that have been made in response to these results.
Budnitz DS, Shehab N, Kegler SR, et al. Ann Intern Med. 2007;147:755-765.
The Beers criteria define certain classes of medications (such as long-acting sedatives and anticholinergics) that are considered "always potentially inappropriate" for geriatric patients, and a recent trial demonstrated a reduction in adverse drug events (ADEs) with an intervention targeting prescribing of these medications. However, many elderly patients require medications that are risky but potentially beneficial if used properly. This analysis of emergency department (ED) visits found that nearly 50% of ED visits due to ADEs were related to medications not considered inappropriate according to the Beers criteria—principally, oral anticoagulants (eg, warfarin), antidiabetic agents (eg, insulin), and antiplatelet agents (aspirin and clopidogrel). The authors argue that focusing on improving prescribing safety for these necessary but higher-risk medications may reduce the large burden of ADEs in the elderly to a greater extent than focusing on use of Beers criteria medications.
Lafata JE, Simpkins J, Kaatz S, et al. Jt Comm J Qual Patient Saf. 2007;33:395-400.
Drug–drug interactions resulting in adverse drug events are common causes of preventable harm to patients. This study used retrospective medical record review to assess if physicians were aware of potential drug–drug interactions, and if so, if patient education was provided. Although physicians generally documented medication lists appropriately, patient education on the potential for drug interactions and their symptoms was generally not documented. Though lack of documentation does not always indicate lack of knowledge or inappropriate management, the study results raise the concern that patients may be left unaware of the risks of polypharmacy.
Computerized physician order entry (CPOE) systems hold the promise of potentially reducing medication errors, especially when coupled with clinical decision support systems (CDSS) that guide clinicians' medication ordering practices. This systematic review did find substantial reductions in potential medication errors in studies of both CPOE and CDSS systems. However, the few studies found were not adequately powered to determine the effects on adverse drug events requiring clinical intervention, and chiefly assessed the effects of "home-grown" CPOE systems. The studies also provided only limited information on implementation issues and potential unintended consequences of CPOE. Such issues will need to be addressed in order to improve the slow pace of uptake of CPOE in US hospitals.
Davis TC, Wolf MS, Bass PF, et al. Ann Intern Med. 2006;145:887-94.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.
Poon EG, Cina JL, Churchill W, et al. Ann Intern Med. 2006;145:426-34.
Bar code technology has been widely recommended to reduce adverse drug events (ADEs) by ensuring the correct medication and dose are dispensed, but prior research has pointed out potential unintended consequences of its use. This AHRQ–funded study measured the incidence of drug dispensing errors and potential ADEs before and after implementation of bar code–assisted dispensing at an academic hospital. Both types of errors were significantly reduced when each dose of medication was scanned, but potential ADEs were increased in a configuration requiring scanning of only one dose per batch. The authors conclude that bar coding systems should be configured to mandate scanning of each dose at least once during the dispensing process.
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