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Annual Perspective: Topics in Medication Safety

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March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Sources of medication omissions among hospitalized older adults with polypharmacy.

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Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.

Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.

The effect of medication reconciliation via a patient portal on medication discrepancies: a randomized noninferiority study.

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Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22:2553-2558.e1.

Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.

Parenteral nutrition safety.

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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.

Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies.

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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.

Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients.

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Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.

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.

When the Lytes Go Out: A Case of Inpatient Cardiac Arrest

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September 30, 2020

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

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

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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.

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

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ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

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.

Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports.

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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.

Reducing anticoagulant medication adverse events and avoidable patient harm.

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Jennings HR, Miller EC, Williams TS, et al. Jt Comm J Qual Patient Saf. 2008;34:196-200.

Hospitalized patients receiving anticoagulants such as warfarin are at high risk for adverse drug events, and reducing the incidence of such errors is one of the Joint Commission's 2008 National Patient Safety Goals. In this study, a hospital system instituted several patient safety measures, including an anticoagulation service and executive walk rounds, to target anticoagulant-related medication errors. The 3-year project resulted in a significant reduction in both bleeding and thrombotic episodes. A case of a warfarin-related adverse event is discussed in an AHRQ WebM&M commentary.

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