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- Error Reporting and Analysis 4
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- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Safety
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Cases & Commentaries
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- Web M&M
Daniel J. Morgan, MD, MS, and Andrew Foy, MD; March 2017
Brought to the emergency department from a nursing facility with confusion and generalized weakness, an older woman was found to have an elevated troponin level but no evidence of ischemia on her ECG. A consulting cardiologist recommended treating the patient with three anticoagulants. The next evening, she became acutely confused and a CT scan revealed a large intraparenchymal hemorrhage with a midline shift.
Journal Article > Study
Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.
Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.
Gould M. Health Service Journal. September 15, 2008:22-24.
This article describes the state of general practitioner incident reporting in the United Kingdom.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.
Journal Article > Study
Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.
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.