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Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Mekonnen AB, McLachlan AJ, Brien J-AE, et al. J Pharm Policy Pract. 2018;11:2.
Researchers conducted eight focus groups to understand how to better engage Ethiopian hospital pharmacists in medication safety. Most expressed enthusiasm about having an active role in safety as long as concerns related to space, resources, and training were addressed. A recent PSNet perspective examined team-based approaches to improving safety during hospital discharge.
Hertig JB, Hultgren KE, Weber RJ. Hosp Pharm. 2016;51:338-44.
Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.
A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.
Makowsky MJ, Schindel TJ, Rosenthal M, et al. J Interprof Care. 2009;23:169-84.
This qualitative study of the integration of pharmacists into inpatient care teams found that while pharmacists were greatly valued, successful integration required careful attention to team structure and workload.
Hospitalized for surgery, a woman with a history of seizures was given an overdose of the wrong medicine due to multiple errors, including an inaccurate preadmission medication list, failure to verify medication history, and uncoordinated information systems.
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr.