Ostrow O, Prodanuk M, Foong Y, et al. Pediatrics. 2022;150:e2021055866.
Appropriate antibiotic prescribing is a core component of antibiotic stewardship programs to reduce the risk of antibiotic-resistant microbes. This study assessed the rate of misdiagnosed pediatric urinary tract infections (UTI) and associated antibiotic use following implementation of a quality improvement intervention. Using three interventions (diagnostic algorithm, callback system, standardized discharge antibiotic prescription), misdiagnosis of UTI decreased by half, and 2,128 antibiotic days were saved.
Smith K, Durant KM, Zimmerman C. Am J Health Syst Pharm. 2022;79:1198-1204.
Clinical decision support (CDS) systems built into electronic health records are designed to alert providers to potentially unsafe orders, but many alerts are ignored or overridden. This article describes the effectiveness of one hospital’s clinical decision support for high-risk medications both before and after alert improvements.
Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.
Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.
Human errors that occur while interacting with electronic health record (EHR) systems can impact patients. This article discusses a keystroke error that delayed the scheduling of an antibiotic for one year. Recommendations to mitigate the potential for similar errors include risk assessment, hard stop use, and daily medication review.
Prescribing antibiotics increases the risk of resistant infections and can lead to patient harm. From December 2019 to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use Program. The goal of the intervention was to support implementation and sustainment of antibiotic stewardship into practice culture, communication, and decision-making. Practices that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute respiratory infections at program completion in November 2020.
Yeh JC, Chae SG, Kennedy PJ, et al. J Pain Symptom Manage. 2022;Epub May 25.
Potentially inappropriate opioid infusion use can result in adverse patient outcomes. This single-site retrospective study found that potentially inappropriate opioid infusions are prevalent (44% of patients receiving opioid infusions during end-of-life care) and were associated with high rates of patient and staff distress.
Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;Epub May 22.
Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.
Drug Enforcement Administration. October 29, 2022.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.
Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.
Fenton JJ, Magnan E, Tseregounis IE, et al. JAMA Netw Open. 2022;5:e2216726.
Adverse events associated with long-term opioid therapy have led to recommendations for dose tapering for patients with chronic pain. This study assessed the long-term risks of overdose and mental health crisis as a result of dose tapering. Consistent with earlier research on short-term risks, results indicate that opioid tapering is associated with increased risk of adverse events up to 24 months after initiation of tapering.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Vallamkonda S, Ortega CA, Lo YC, et al. Stud Health Technol Inform. 2022;290:120-124.
Prior research has found that electronic health record (EHR) implementation has introduced risks to patient safety. Using data from one hospital’s EHR system, this study reviewed active allergy alerts in patient records and concluded that 37% of those records required reconciliation of allergy information across different areas of the EHR. These findings highlight the need for automated reconciliation algorithms and clinical decision support tools to help clinicians identify potential allergy discrepancies and avoid patient safety risks.
Bicket MC, Waljee JF, Hilliard P. JAMA Health Forum. 2022;3:e221356.
Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety. The deadline for submitting nominations for the 2022 award cycle is September 9.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
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