Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Frid S, Zapico V, Mansilla A, et al. Stud Health Technol Inform. 2019;264:581-585.
Clinical provider order entry (CPOE) and clinical decision support systems (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.
de Araújo BC, de Melo RC, de Bortoli MC, et al. Front Pharmacol. 2019;10:439.
Prescribing errors are common and can result in patient harm. This review summarizes four key options to reduce prescribing errors: prescriber education, effective use of computerized alert systems at the clinical interface, use of tools and guidance to inform practice, and multidisciplinary teams that include pharmacists.
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