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Scott A. Strassels, PharmD, PhD, BCPS; August 2006
In anticipation of discharge, a patient's opiate medication is changed from an immediate-release to a long-acting formbut the dose was incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the ICU.
Journal Article > Study
Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.
To grade progress since release of the landmark Institute of Medicine (IOM) report, this AHRQ-funded study examined the status and evolution of patient safety systems through a survey of acute care hospitals in Missouri and Utah. Investigators characterized their assessment based on variables that included presence of computerized physician order entry systems, computerized test results, evaluation of adverse drug events, specific patient safety policies, use of data in patient safety programs, drug administration and safety procedures, error reporting processes, prevention policies, and root cause analyses. More than 100 hospitals completed the survey in 2002 and again in 2004. Findings demonstrated only modest improvements in certain areas with variability noted in others. For instance, surgical areas and medication processes seemed to embrace the greatest level of patient safety systems. However, the authors point out that the overall findings fall short of the IOM recommendations and necessitate a more intensive agenda for accelerated improvements. An accompanying editorial (link below) provides an overview of the factors and challenges involved in promoting change to improve patient safety.
Journal Article > Study
Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial.
Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G. Pediatrics. 2005;116:1299-1302.
This study discovered that a preprinted and structured order form was half as likely to be associated with a medication error compared with use of traditional blank order forms. Using two pediatric emergency physicians who were blinded to the order form type, investigators report differential rates and severity of medication errors from physician review of patient charts. The study is the first randomized controlled trial to demonstrate that a low-cost intervention can significantly reduce medication errors in pediatric emergency room patients. Such order sets may provide a useful tool while many hospitals await full implementation of computerized physician order entry systems.