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Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2021;Epub Jul 14.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Koeck JA, Young NJ, Kontny U, et al. Front Pediatr. 2021;9:633064.
Medication safety in children is a patient safety priority. This systematic review explored interventions to reduce medication dispensing, administration, and monitoring errors in pediatric healthcare settings. The majority of identified studies used “administrative controls” to prevent errors, but those implementing higher-level interventions (such as smart pumps and mandatory barcode scanning) were more likely to result in error reduction.
Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;181(10):1383-1384.
Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.
Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4(8):e2123007.
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;Epub Jun 12.
Patient safety concerns in community pharmacies have been documented in the media. This study sought to examine the association of working conditions and patient safety. Results indicate that while all participants reported negative company climate and workflow, those in chain pharmacies reported significantly more fear of speaking up about patient safety issues than those in independent, big box, or grocery pharmacies.
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28(7):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.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;Epub Jul 22.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;Epub May 23.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.

Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff.  This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;Epub Mar 2.
Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Parry C. The Pharmaceutical JournalApril 22 2021.

Weight-based prescribing in children harbors challenges to accurate medication dosing. This story discusses an examination of factors contributing to ten-fold medication errors in pediatric care. The author summarizes an ongoing investigation which has identified polypharmacy and information system weaknesses as being among the contributors to the problem.
Fudge N, Swinglehurst D. BMJ Open. 2021;11(2):e042504.
Polypharmacy – particularly in older adults – can increase the risk of adverse drug events. Based on an ethnographic case study of community pharmacies in England, the authors found that polypharmacy was a pervasive problem but rarely discussed as a safety concern and not actively challenged by pharmacy staff.
Whaley C, Bancsi A, Ho JM-W, et al. BMC Health Serv Res. 2021;21(1).
Communicating medication indications with the healthcare team and patients can improve medication adherence and patient safety. Based on qualitative interviews with prescribers, researchers found that prescribers were open to sharing medication indications and understood the safety benefits, but raised concerns about the impact on their workflow and workload.

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.
Samad F, Burton SJ, Kwan D, et al. Pharmaceut Med. 2021;35(1):1-9.
Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.