Narrow Results Clear All
Search results for ""
- Clinical Pharmacist Involvement
- Computerized Adverse Event Detection
- Medication Errors/Preventable Adverse Drug Events
- North America
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.
Journal Article > Study
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.