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Cases & Commentaries
- Web M&M
Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD; July 2011
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
Journal Article > Study
Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.
Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.
The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.
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.