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Cases & Commentaries
- Web M&M
Steven R. Kayser, PharmD; February 2007
A woman admitted to the hospital for cardiac transplantation evaluation is mistakenly given warfarin despite an order to hold the dose due to an increase in her INR level.
Journal Article > Study
Ward MM, Evans TC, Spies AJ, Roberts LL, Wakefield DS. Am J Med Qual. 2006;21:101-108.
This study assessed a representative group of hospitals to evaluate their perception and priority of each of the National Quality Forum's (NQF) 30 "safe practices." Investigators analyzed responses from 100 hospitals and determined higher ratings for priority than for progress of the practices overall. They noted the largest discrepancy between priority and progress in creating a safety culture with the highest progress rating for increasing safe medication use. Based on evaluating individual hospital characteristics, the authors also identified 20 safe practices not associated with measures of hospital structure, capacity, or resources. These particular findings may guide other organizations trying to develop strategic safety plans with respect to NQF safety recommendations.
Journal Article > Study
Lesar TS. Hosp Pharm. 2006;41:1053-1066.
Error in medication prescribing is a well-described problem in the hospital setting. This study sought to further characterize prescribing errors by determining the incidence of one specific type of error—errors in the route of administration. These errors were common, most frequently involving prescribing for the wrong route (eg, orally instead of intravenously), and cardiovascular drugs were most often implicated. The author provides suggestions for means of preventing these errors. A prior study by Lesar was one of the first to characterize the incidence of medication error in a teaching hospital setting, and he discusses the implications of error in the route of administration in a WebM&M commentary.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. April 11, 2008;(39):1-5.
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these strategies is then assessed on Joint Commission site visits at health care organizations nationwide. This newly released Sentinel Event Alert focuses on pediatric medication errors, in light of recent data demonstrating that such errors are more common than previously thought and may not be prevented by standard medication error preventive measures. The alert highlights the importance of dosing errors (eg, weight-related and calculation-related errors), as well as the fact that technology used to reduce medication errors in adults must be adapted for children. A prior study documented the types of medication errors at an academic children's hospital and explored means of preventing such errors.
Journal Article > Study
Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2008;65:827-843.
The American Society of Health-System Pharmacists (ASHP) offers policy positions, statements, and guidelines to ensure safe inpatient medication administration. This study highlights their findings from a survey of more than 1200 pharmacy directors across the country. Major trends identified since past administrations of the same survey include a gradual decline in use of the formulary system, an increase in the use of clinical practice guidelines, a growth in methods to improve prescribing practices, and rapid changes in practice driven by accreditation standards. The authors conclude that pharmacists are responding to changes in the health care system and driving efforts to improve medication use.
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.
Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
This article describes how one health care system used a multi-event analysis process to identify medication errors, implement system-level improvements, and reduce adverse events.