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Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis.

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Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.

The CancelRx system is a health information technology-based intervention intended to mitigate the challenges of communicating medication discontinuation. Using secondary data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that implementing the CancelRx system resulted in a significant increase in successful medication discontinuations for controlled substances.

Mapping the resilience performance of community pharmacy to maintain patient safety during the Covid-19 pandemic.

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Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;Epub Jan 28.

The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.

Targeted Medication Safety Best Practices for Hospitals.

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Horsham, PA: Institute for Safe Medication Practices; 2022.

This updated report outlines 19 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 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications.

Including the reason for use on prescriptions sent to pharmacists: scoping review.

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Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8: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.

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

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Chaker A, Omair I, Mohamed WH, et al. Am J Health Syst Pharm. 2022;79:187–192.

The Institute for Safe Medication Practices recommends compounding pharmacies use technology and automation to improve patient safety. Researchers assessed the workflow and workforce requirements of one hospital’s sterile preparation center (SPC) following implementation of these recommendations. The average time to prepare each type of medication was used to determine pharmacy staffing workforce requirements.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

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October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Purchase of prescription medicines via social media: a survey-based study of prevalence, risk perceptions, and motivations.

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Moureaud C, Hertig JB, Dong Y, et al. Health Policy (New York). 2021;125:1421-1429.

Based on survey responses from 1,002 participants, this study evaluated how social media users assess, interact and engage with information related to the illegal sales of prescription medicines. Findings suggest that individuals generally perceive online pharmacies and social media platforms to be safe and respondents are confident in their ability to acquire legitimate medicines. The authors note that this false confidence has the potential to lead to patient harm given the prevalence of counterfeit and substandard medication available on these platforms.

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

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Institute for Safe Medication Practices. October 26, 2021.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

A standardized formulary to reduce pediatric medication dosing errors: a mixed methods study.

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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.

Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review.

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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.

Electronic health record interoperability-why electronically discontinued medications are still dispensed.

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Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;181:1383-1384.

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.

Effect of a mobile app on prehospital medication errors during simulated pediatric resuscitation: a randomized clinical trial.

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Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4: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.

Perceptions of working conditions and safety concerns in community pharmacy.

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Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;61:761-771.

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.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

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Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.

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.

ASHP guidelines on the safe use of automated dispensing devices.

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Cello R, Conley M, Cooley TW, et al. Am J Health Syst Pharm. 2021;79:e71-e82.

This document shares goals and objectives to enhance use of automated dispensing devices for pharmacists, other practitioners, and information system professionals.

Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.

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Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;30:1021-1030.

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.

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.

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.

Pharmacist and prescriber responsibilities for avoiding prescription drug misuse.

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AMA J Ethics. 2021;23:E471-479.

The prescribing and provision of medications sought after for abuse carries with it a professional obligation to limit access to medications when requests are of uncertain origin. This article describes legal, cognitive, and organizational culture influences on safe prescribing of controlled substances.

Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.

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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.

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