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The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

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Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.

Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.

Decreasing misdiagnoses of urinary tract infections in a pediatric emergency department.

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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.

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;Epub Jun 30.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Tipping the balance: a systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings.

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Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.

Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.

Challenges of Diabetes Management and Medication Reconciliation

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August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Impact of an electronic health record alert on inappropriate prescribing of high-risk medications to patients with concurrent "do not give" orders.

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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.

Factors influencing medication errors in the prehospital paramedic environment: a mixed method systematic review.

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Walker D, Moloney C, SueSee B, et al. Prehosp Emerg Care. 2022;Epub Jun 27.

Safe medication management practices are critical to providing safe care in all healthcare settings. While there are studies reporting a variety of prehospital adverse events (e.g., respiratory and airway events, communication, etc.), there have been few studies of medication errors that occur in prehospital settings. This mixed methods systematic review of 56 studies and case reports identifies seven major themes such as organizational factors, equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors, and cognitive factors as contributing to safe medication management.

Medication orders with future start dates: how far away Is too far?

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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.

Assessment of changes in visits and antibiotic prescribing during the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use and the COVID-19 Pandemic.

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Keller SC, Caballero TM, Tamma PD, et al. JAMA Netw Open. 2022;5:e2220512.

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.

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Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2022;Epub Jul 5.

Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.

Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation.

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Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.

Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

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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.

National Prescription Drug Take Back Day.

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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.

Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults with possible bacteremia.

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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.

Long-term risk of overdose or mental health crisis after opioid dose tapering.

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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.

Developing and aligning a safety event taxonomy for inpatient psychiatry.

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Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.

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.

Medication Safety Events Related to Diagnostic Imaging

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July 8, 2022

This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.

An Incomplete Anesthesia History Leads to Adverse Outcomes

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July 8, 2022

This WebM&M highlights two instances where incomplete documentation of patient history led to complications related to anesthesia administration. The commentary discusses the importance of a thorough preoperative history and preoperative evaluation.

Ambulatory medication safety in primary care: a systematic review.

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Young RA, Fulda KG, Espinoza A, et al. J Am Board Fam Med. 2022;35:610-628.

Identifying barriers and facilitators of medication safety is a patient safety research priority. In this systematic review characterizing the research on medication safety in primary care, researchers found that the majority of studies focused on high-risk populations (such as older adults with polypharmacy) and measured potential harms (such as potentially inappropriate prescribing or potential prescribing omissions) rather than actual harms.

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

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Brown A, Cavell G, Dogra N, et al. Int J Med Inform. 2022;164:104780.

Alert fatigue and subsequent overrides are known contributors to preventable adverse events particularly for high-risk drug-drug interactions. Researchers assessed prescribers’ actions following an alert for new prescriptions of Low Molecular Weight Heparins (LMWHs) to patients currently prescribed Direct Acting Anticoagulants (DOACs). More than half of the alerts were overridden but were appropriate and justified in most cases.

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