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ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.

Delays in diagnosis and treatment during life-threatening emergencies such as strokes can result in irreversible patient harm. This article discusses a variety of factors contributing to errors in administering hypertonic sodium chloride in emergent situations. The piece shares recommendations touching on various elements of the medication delivery process to enhance safety.

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.

Breuker C, Macioce V, Mura T, et al. J Patient Saf. 2021;17(7):e645-e652.
In this prospective observational study, hospital pharmacy staff obtained the best possible medication history for adult patients at admission to and discharge from one French hospital. Unintended medication discrepancies were identified in nearly 30% of patients. Most medication errors were omissions and risk of error increased with the number of medications.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.

Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Res Social Adm Pharm. 2021;17(8):1426-1432.
This multicenter prospective study explored the effect of medication reconciliation on patient-reported, potential adverse events post-discharge. Although the intervention – which consisted of a pharmacy team providing patient both education and medication review upon admission and discharge as well as information transfer to primary care – did not decrease the proportion of patients with adverse events, it did reduce the number of potential adverse events.
Kabir R, Liaw S, Cerise J, et al. J Pharm Pract. 2021:089719002110212.
The best possible medication history (BPMH) is the gold standard of medication reconciliation of a patient’s prescribed and over-the-counter medications. In this study, Certified Pharmacy Technicians (CPhTs) obtained BPMH from patients admitted through the emergency department. In Quality Assurance reviews, the CPhTs identified medication discrepancies at a similar rate to pharmacists, indicating that CPhTs may be a cost-effective alternative to pharmacists in obtaining BPMH.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38(4):341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.  

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure. 

March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.

A 58-year-old female receiving treatment for transformed lymphoma was admitted to the intensive care unit (ICU) with E. coli bacteremia and colitis secondary to neutropenia, and ongoing hiccups lasting more than 48 hours. She was prescribed thioridazine 10 mg twice daily for the hiccups and received four doses without resolution; the dose was then increased to 15 mg and again to 25 mg without resolution.

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessio

ISMP Medication Safety Alert! Acute care edition. July 30, 2020;25(15).

This article reports on the results of a survey on the use of practices to improve the safety of prescribing and dispensing of long-acting opioids and use of the override feature in automated dispensing cabinets. The approximately 250 hospitals responding shared experience indicating weakness in implementing improvement efforts on the two practices studied. The results found that hospitals employing a medication safety officer had stronger uptake of the best practices.
ISMP Medication Safety Alert! Acute Care Edition. 2020;25(12).
Successful development of a just culture centers on understanding different types of flawed human behavior and designing effective organizational responses to these failures. This article compares human error, at-risk behavior, and reckless behavior to suggest systems design changes for patient safety programs to generate opportunities for improvement.  
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 
Erickson SR, Kamdar N, Wu C-H. Am J Intellect Dev Disabil. 2019;125(1):37-48.
Prior research has found that children with intellectual or developmental disabilities (IDD) may experience poor quality care and are at risk for adverse events, but less is known about risk among adults with IDD. Using data from a nationally representative database, the authors compared hospitalizations due to adverse medication events among adults with IDD compared with the general adult population and found that adults with IDD were at a significantly greater risk of having a hospital admission due to an adverse event (odds ratio, 1.28).
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
Kennedy AR, Massey LR. Am J Health Syst Pharm. 2019;76:1481-1491.
This Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that provide care to pediatric patients. The authors identify risks and provide recommendations to ensure safe care of children including optimizing technology, utilizing external resources, and ensuring a pediatric pharmacist is in place.
Frid S, Zapico V, Mansilla A, et al. Stud Health Technol Inform. 2019;264:581-585.
Clinical provider order entry (CPOE) and clinical decision support systems  (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.   
Parker H, Farrell O, Bethune R, et al. Br J Clin Pharmacol. 2019;85(10):2405-2413.
Despite process changes and availability of new technologies, prescribing errors (one type of medication administration errors) remain a serious safety problem. This article describes a single-site pharmacist-led intervention that involved doctors-in-training (residents) reviewing video footage of their patient visits with a pharmacist. The feedback intervention resulted in a significant reduction in prescribing errors and was found acceptable and feasible by participants.