Kukielka E, Jones R. Patient Safety. 2022;4:49-59.
Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Goldberg EM, Marks SJ, Merchant RC, et al. Acad Emerg Med. 2021;28:248-252.
This analysis found that only 23% of older adults in the Emergency Department had complete agreement between self-reported medications and pharmacy dispensing records. Over half of patients omitted antibiotics from self-report, which can result in adverse events, as antibiotics can have potentially fatal interactions with many medications.
Nguyen AD, Lam A, Banakh I, et al. J Pharm Pract. 2020;33:299-305.
This study evaluated the impact of the PeRiopErative and Prescribing (PREP) pharmacist, who is responsible for obtaining the best possible medication history and preparing discharge prescriptions. Results indicate that the inclusion of the PREP pharmacist on the multidisciplinary surgical team improved the accuracy of medication histories, inpatient prescribing, and discharge prescriptions for high-risk patients.
Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.
Kram BL, Trammel MA, Kram SJ, et al. Ann Pharmacother. 2019;53:596-602.
This prospective uncontrolled intervention study found that pharmacists and pharmacy technicians were able to obtain a medication history for most critically ill patients. They uncovered a significant number of medication discrepancies that could lead to adverse drug events and recommend medication history-taking for all critically ill patients.
Greer JA, Haischer-Rollo G, Delorey D, et al. Cureus. 2019;11:e4096.
This pre–post study examined the effect of team training on an emergency response team's performance in a perinatal emergency simulation. Following the training, performance in the simulation identified more latent safety threats and adherence to a safety checklist increased. The authors suggest that team training can enhance maternal safety.
Bergl PA, Nanchal RS, Singh H. Ann Am Thorac Soc. 2018;15:903-907.
Elements of critical care can influence the reliability of diagnosis, teamwork, and care delivery. This commentary recommends areas for research to reduce diagnostic error in the intensive care unit. The authors highlight the need for intensivist involvement to define distinct roles and actions in their specialty for diagnostic improvement.
Shah D, Manzi S. Pediatr Emerg Care. 2018;34:497-500.
Clinical pharmacist supervision improves medication safety in many health care settings. In this study, pharmacists in a pediatric emergency department (ED) reviewed all discharge prescriptions the day after patients left the ED and contacted prescribers to address safety hazards. Over a 1-year period, pharmacists intervened rarely (0.25% of prescriptions), averted 10 incidents of moderate or major harm, and worked 45 additional minutes per day.
Fernando SM, Reardon PM, Bagshaw SM, et al. Crit Care. 2018;22:67.
Patients evaluated by a rapid response team at night were less likely to be transferred to the intensive care unit and more likely to die in the hospital compared to patients evaluated during the daytime. A previous WebM&M commentary discussed a preventable adverse event occurring in part due to less intensive nighttime staffing.
Team strategies are key to improving complex care processes. This review focuses on cardiothoracic surgery and the need for team approaches to enhance the safety of care in this specialty. The authors suggest that nontechnical skill development for surgical team leaders and structured communication can improve team performance.
Hermanspann T, Schoberer M, Robel-Tillig E, et al. Front Pediatr. 2017;5:149.
Parenteral nutrition dosing and preparation is complex and error-prone. This prospective study found that even with computer provider order entry, clinical pharmacist review identified errors in 4% of orders. The authors suggest that pharmacist review be included as part of the parenteral nutrition ordering process in order to prevent adverse events.
Rubin EC, Pisupati R, Nerenberg SF. Hosp Pharm. 2016;51:396-404.
This retrospective study found that pharmacy technicians were able to collect a more accurate medication list for patients in the emergency department compared to the usual medication list obtained by other personnel. This finding suggests that better integration of the pharmacy team into emergency care could improve patient safety, consistent with previous studies investigating the role of pharmacists in emergency departments.
Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.
Jones SL, Ashton CM, Kiehne L, et al. Jt Comm J Qual Patient Saf. 2015;41:483-91.
A protocolized early warning system to improve sepsis recognition and management was associated with a decrease in sepsis-related inpatient mortality. The protocol emphasized early recognition by nurses and escalation of care by a nurse practitioner when indicated. An AHRQ WebM&M commentary describes common errors in the early management of sepsis.
This controlled study evaluated the effect of a protocolled pharmacist intervention—which included medication reconciliation and regular medication review—on medication errors in elective surgery patients. There was no difference in the incidence of adverse drug events compared to patients receiving usual care.
Amaral ACK-B, McDonald A, Coburn NG, et al. BMJ Qual Saf. 2015;24:764-8.
There is a consensus in the safety field that organizations must use multiple methods of detecting errors and adverse events, as individual approaches vary in their ability to identify different types of safety issues. Rapid response systems (RRSs) have been widely deployed to detect and stabilize deteriorating hospitalized patients, and this study investigated whether analysis of RRS activations could be used to identify preventable hazards. Systematic review of patients seen by the RRS revealed that almost 20% had experienced an adverse event, 80% of these were preventable, and most were not reported to the institution's incident reporting system. Hospitals should consider formal review of RRS activation as a trigger for identifying adverse events.
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