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Cases & Commentaries
- Web M&M
Hedy Cohen, RN, BSN, MS; February-March 2009
New medication administration policies at one hospital cause a patient to receive two doses of her daily medication within a few hours, when only one dose was intended.
Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
Journal Article > Commentary
Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.
Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.
The authors suggest a model process utilizing failure mode and effects analysis to effectively implement emerging technologies that help minimize medication error.
Journal Article > Study
Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions.
Malone DC, Abarca J, Skrepnek GH, et al. Med Care. 2007;45:456-462.
Medication safety programs continue to focus on minimizing potential drug interactions. This study discovered that higher pharmacy workload, defined as the number of prescriptions dispensed per pharmacist work hour, led to increased risk of dispensing a potentially unsafe medication. Investigators combined survey data from community pharmacies with pharmacy claim data and found that pharmacist staffing and levels of automation also predicted dispensing of potential drug interactions. The study did not address whether these potential drug interactions led to actual adverse events. Questions about adequate pharmacist staffing, similar to research published in nursing, could provide important information to pharmacies and hospitals about safety and quality.
Journal Article > Commentary
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.
ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.
This article discusses a medication error associated with a new smart pump system and describes strategies to prevent errors when well-established processes are changed.