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- Device-related Complications 2
- Medication Errors/Preventable Adverse Drug Events
Search results for "Web Resource"
- Web Resource
- Ordering/Prescribing Errors
FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
FDA Safety Communication: use caution with implanted pumps for intrathecal administration of medicines for pain management.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
Journal Article > Government Resource
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.
Journal Article > Government Resource
García MC, Dodek AB, Kowalski T, et al. MMWR Morb Mortal Wkly Rep. 2016;65:1125-1131.
Adverse drug events related to opioid medications are a significant patient safety concern. This analysis of insurer claims data demonstrated that changing opioid prescribing requirements, including implementing patient–provider agreements, requiring prior authorization, and enforcing quantity limits, led to a decline in opioid prescribing. The authors recommend that insurers implement policies from the Centers for Disease Control and Prevention opioid guidelines to improve safety.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 4, 2016.
This announcement alerts prescribers to differences in two oral formulations of the same medication that can lead to dosing errors. The FDA suggests that clinicians specify dosage form, strength, and frequency on prescriptions for this drug to reduce the risk of patient harm and recommend that pharmacists follow up with prescribers if such information is missing.
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
FDA cautions about dose confusion and medication errors for antibacterial drug Zerbaxa (ceftolozane and tazobactam).
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; May 20, 2015.
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
This article analyzed reports of medication errors due to patient allergies and found that lack of patient or drug information contributed to many of these errors.
FDA Public Health Advisory [US Food and Drug Administration Web site]. March 11, 2008.
This announcement alerts parents and health care professionals about the potentially fatal dangers of Tussionex Pennkinetic Extended-Release Suspension, a prescription cough medicine that should not be used in children younger than 6 years.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 13, 2007.
This announcement provides specific instructions on safe prescribing of a cancer pain medication in response to several patient deaths associated with off-label use.
Rapid Response Report 2. London, UK: National Patient Safety Agency; September 3, 2007.
This announcement details the potential for errors and near misses associated with an injectable medication that is available in several formulations.
PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.
This article shares findings from a workgroup that assessed the efficacy of pharmacy computer systems in detecting unsafe medication orders. The 30 Pennsylvania hospitals that participated in the workgroup found that their systems were not catching all unsafe orders.
Journal Article > Government Resource
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.
The Centers for Disease Control and Prevention (CDC) investigated adverse events related to cough and cold medications in infants. The investigation found three instances in which these medications were considered the underlying cause of death.
Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.
This video segment warns about potential dosing errors for an epileptic seizure treatment due to equipment design and provides instructions to minimize user error.
Tools/Toolkit > Government Resource
Huntington Valley, PA: Institute for Safe Medication Practices.
This Web site includes tools to help raise awareness about potential medication errors associated with using certain abbreviations. The tools are made available by Institute for Safe Medication Practices (ISMP) and U.S. Food and Drug Administration (FDA) as part of their national educational effort to eliminate the use of these abbreviations.
Consumers Filling U.S. Prescriptions Abroad May Get the Wrong Active Ingredient Because of Confusing Drug Names.
FDA Public Health Advisory [US Food and Drug Administration Web site]. January 2006.
This U.S. Food and Drug Administration advisory alerts clinicians and consumers to potential mistakes in prescriptions purchased abroad. The advisory includes a table of medications known to contain different active ingredients when purchased outside the United States.