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- WebM&M Cases 3
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- Medication Errors/Preventable Adverse Drug Events
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Search results for ""
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important medication information such as a list of allergies, prescriptions, dosages, and conditions being treated.
Suares W. FOX 25 KOKH-TV. July 30, 2014.
This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.
Pierrotti A. USA Today. August 18, 2014.
Jaffe I, Renincasa R. Morning Edition. National Public Radio. December 8–9, 2014.
Overprescribing of medications is a common problem in nursing homes. This two-part radio segment reports on the inappropriate use of antipsychotic medications as a chemical restraint for patients with dementia. The first part introduces the issue and includes insights from families that have experienced harm due to the practice. The second segment discusses programs that the Centers for Medicare and Medicaid Services has put in place to address the problem through a more patient-centered approach to care and suggests strengthening penalties against organizations that overuse antipsychotics.
Webb J. Drug Topics. March 10, 2015.
Pharmacies can serve as gatekeepers to ensure patients receive the correct medications. A 10-year study of claims data found that the majority of claims were related to wrong dose and wrong drug dispensing errors. This news article discusses injuries that resulted from the errors and provides recommendations to augment safety, including the design and use of order review and quality control systems to reduce the risk of human error in pharmacy services.
Tavernise S. New York Times. January 15, 2015.
This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.
McKinnon C. WBZ-TV. February 13, 2015.
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.
Meyer T. WKYC-TV. May 20, 2015.
Reporting on how production pressures in pharmacies contribute to prescription errors that lead to patient harm, this news video segment features insights from the father of a child who died following a medication error and the pharmacist who lost his license and served a prison sentence due to this incident.
Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.
ISMP Safe Medicine. July/August 2015;13:1-3.
Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.
Roe S, King K. Chicago Tribune. February 10–13, 2016.
Drug interactions can be hazardous to patients, particularly when combined with risk factors such as age and use of medications for chronic conditions. This series of news reports discusses the problem of drug interactions, including one patient's experience of severe harm and researchers' use of data mining to identify medication pairs linked to high-risk interactions. The series also includes a list of steps patients can take to reduce risk of harmful interactions between medicines they take.
Brody JE. New York Times. November 30, 2015.
Web Resource > Government Resource
Centers for Disease Control and Prevention.
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Journal Article > Study
Shiffman S, Cotton H, Jessurun C, Rohay JM, Sembower MA. J Am Pharm Assoc (2003). 2016;56:495-503.
Poor health literacy is associated with the misunderstanding of medication labels, which can lead to adverse drug events. This study sought to assess how adding an acetaminophen icon to the labels of acetaminophen-containing medications affects consumers' ability to avoid unintentional overdose, which is known to cause liver damage. Investigators found that presence of the icon reduced the likelihood of medication errors by 53%, and they concluded that the icon may particularly benefit those with lower health literacy. A past WebM&M commentary discussed a case of liver injury caused by incorrect dosing of acetaminophen.
Gorman A. Kaiser Health News. August 30, 2016.
Older patients are particularly vulnerable to medication errors, as they are often prescribed multiple medications for chronic conditions. This news article reports on complexities associated with managing medications in older patients, including how miscommunication between care team members and patient misunderstanding of postdischarge medication changes can increase risks and contribute to preventable harm. A recent WebM&M commentary discussed strategies to safely manage medications in older patients and highlighted the importance of medication reconciliation.
Journal Article > Study
Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2016;138:e20160357.
Misinterpretation of medication labels is a well-recognized source of medication error in the outpatient setting, especially among patients with low health literacy. This randomized controlled study looked at how units of measurement on medication labels and dosing tool characteristics affected dosing errors with regard to liquid medications in pediatrics. About 84% of parents made at least one dosing error, and 21% made at least one large error, defined as administering more than double the dose. Researchers concluded that the use of oral syringes resulted in fewer dosing errors than cups, especially when administering small doses. The authors conclude that oral syringes should be recommended when dispensing liquid medications in pediatrics. A prior WebM&M commentary discussed a pediatric dosing error.
Furfaro H. Wall Street Journal. September 25, 2016.
Medication errors in pediatric care are common in the hospital and at home. This newspaper article reports on problems associated with medication safety among pediatric patients and highlights several tools both clinicians and parents can use to enhance safety when administering medicine to children, including dosage calculators and pictures depicting medication administration processes.
Journal Article > Study
Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.
Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.
Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.