Librov S, Shavit I. J Pain Res. 2020;13:1797-1802.
This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.
Aghili M, Neelathahalli Kasturirangan M. JBI Evid Implement. 2021;19:21-30.
This study evaluated the impact of clinical pharmacist-led interventions on medication errors and preventable adverse drug events among patients in the ICU. The clinical pharmacist performed medication chart review, patient monitoring, and attended medical rounds in order to evaluate the appropriateness of the pharmacological treatment, identify and report drug-related issues, and provide evidence-based recommendations for the management of medication errors. When the pharmacist’s recommendations were implemented by prescribing physicians, approximately half of medication errors were intercepted before reaching the patient, resulting in fewer preventable adverse drug events.
Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Kadmon G, Pinchover M, Weissbach A, et al. J Pediatr. 2017;190:236-240.e2.
This observational study found that prescription errors were less frequent in 2007, shortly after computerized physician order entry implementation, than in 2015. Changes to decision support in 2015 led to a subsequent reduction in errors in 2016. The authors argue for surveillance of electronic prescribing in order to detect medication errors.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Prgomet M, Li L, Niazkhani Z, et al. J Am Med Inform Assoc. 2017;24:413-422.
While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.
Cho I, Park H, Choi YJ, et al. PLoS One. 2014;9:e114243.
This study reviewed prescriptions following implementation of a computerized provider order entry system. More than half of examined prescriptions had medication errors, most often related to incorrect documentation of verbal orders. These results add to concerns about unintended consequences of computerized provider order entry.
Lifshitz AE, Goldstein LH, Sharist M, et al. Am J Emerg Med. 2012;30:726-31.
This study discovered that medication errors were more common in the emergency department setting than in emergency vehicles, and patients requiring multiple medications were at higher risk for medication errors.
Platte B, Akinci F, Güç Y. Am J Manag Care. 2010;16:e245-50.
The accuracy of medication profiles at a small hospital was superior to that documented in other studies, a finding which the authors attribute to use of an integrated medication reconciliation system within the electronic medical record.
Kadmon G, Bron-Harlev E, Nahum E, et al. Pediatrics. 2009;124:935-940.
Hospitalized children are particularly vulnerable to medication errors due to the complexity of weight-based dosing and the resulting potential for calculation errors. Computerized provider order entry (CPOE) has been widely advocated as a means of preventing such errors. In this study, implementation of a CPOE system did not initially reduce adverse drug events in a pediatric intensive care unit. However, when a decision support system for calculating weight-based dosages was added to the CPOE system, medication errors declined significantly. A 2008 Sentinel Event Alert published by The Joint Commission highlighted the prevalence of pediatric medication errors and recommended potential solutions.
Long A-J, Chang P, Li Y-C, et al. Int J Med Inform. 2008;77.
This study used a log file within a computerized physician order entry (CPOE) system to understand the role physician- and policy-related variables, as well as patient resistance, played in responding to electronic reminders about drug duplication orders.
Song L, Chui WCM, Lau CP, et al. J Clin Pharm Ther. 2008;33:109-14.
This analysis of adverse drug events at a hospital in Hong Kong found that dosing errors were most common, and more errors were associated with handwritten prescriptions than computerized provider order entry.
Vardi A; Efrati O; Levin I; Matok I; Rubinstein M; Paret G; Barzilay Z.
The authors describe the implementation of computerized physician order entry with decision support in one pediatric hospital. After the system was in place, no resuscitation medication errors transpired.
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