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.
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.
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.
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.
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.
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.
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.
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.
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.
Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. BMC Health Serv Res. 2022;22:722.
Medication reconciliation can reduce medication errors, but implementation practices can vary across institutions. In this study, researchers compared data for patients from six hospitals and different clinical departments and found that hospitals differed in the number and type of medication reconciliation interventions performed. Qualitative analysis suggests that patient mix, types of healthcare professionals involved, and when and where the medication reconciliation interviews took place, influence the number of interventions performed.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
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.
Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;Epub May 6.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
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