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Approach to Improving Safety
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Search results for "Active Errors"

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Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Journal Article > Study

Quality of handoffs in community pharmacies.

Abebe E, Stone JA, Lester CA, Chui MA. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

Journal Article > Study

All consumer medication information is not created equal: implications for medication safety.

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.

Web Resource > Multi-use Website

Standardize 4 Safety.

American Society of Health-System Pharmacists.

Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.

Newspaper/Magazine Article

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.

Audiovisual

Is pressure causing drug errors?

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.

Journal Article > Review

Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis.

Anderson K, Stowasser D, Freeman C, Scott I. BMJ Open. 2014;4:e006544.

This systematic review examined prescribing of potentially inappropriate medications and found that prescriber characteristics (such as clinical inertia and lack of knowledge) and system characteristics (such as insufficient time to review medications and limited availability of nonmedication treatments) both contributed to persistent prescribing of medications associated with increased risks. These findings emphasize the need for fundamental health care reform in order to improve medication safety.

Newspaper/Magazine Article

Reminder: pay attention to the appearance of your medicines.

ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.

This newsletter article describes an incident involving a patient who noticed that the tablets in her prescription refill had a different marking than usual, alerting her that she might have received an incorrect medication which was confirmed by the pharmacist. Tips for patients to avoid medication errors include being familiar with how their medicines look and checking prescriptions before leaving the pharmacy. Practitioners can help prevent these errors by counting and labeling prescriptions one at a time and performing patient consultations.

Audiovisual

Family matters: pharmacy mix-ups.

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.

Journal Article > Commentary

Pharmacists in pharmacovigilance: can increased diagnostic opportunity in community settings translate to better vigilance?

Rutter P, Brown D, Howard J, Randall C. Drug Saf. 2014;37:465-469.

Pharmacists continue to play a critical role in reducing medication errors. Exploring ways to enhance the role of community pharmacists in medication safety, this commentary advocates for providing education about the importance of reporting adverse drug events and training to improve diagnostic skills.

Journal Article > Study

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

Franklin BD, Reynolds M, Sadler S, et al. BMJ Qual Saf. 2014;23:629-638.

This study of medication dispensing errors at community pharmacies found that electronic transmission of prescriptions resulted in increased omission of the medication indication, but that other error types did not change. These findings suggest that electronic prescribing alone is not sufficient to address outpatient dispensing errors.

Tools/Toolkit > Government Resource

Community Pharmacy Survey on Patient Safety Culture: Community Pharmacy Survey Toolkit.

Rockville, MD: Agency for Healthcare Research and Quality; July 2014.

This survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies. The data collection process for the latest national comparison is now closed.

Journal Article > Study

E-prescribing errors in community pharmacies: exploring consequences and contributing factors.

Odukoya OK, Stone JA, Chui MA. Int J Med Inform. 2014;83:427-437.

This direct observation study found that various medication errors related to electronic prescribing occur in community pharmacies. Contributing factors included poor inter-operability between pharmacy and clinic systems, inadequate technology usability, and data entry errors. This finding underscores the growing safety concerns associated with medication prescribing in ambulatory care.

Journal Article > Study

Uptake of quality-related event standards of practice by community pharmacies.

Boyle TA, Bishop AC, Overmars C, et al. J Pharm Pract. 2015;28:442-449.

This analysis of community pharmacy practices found that while most have reporting of medication errors and near misses in place, few establish improvement plans or apply systems approaches to address errors. This finding underscores the need to learn from events and implement changes to resolve safety issues.

Journal Article > Study

How do community pharmacies recover from e-prescription errors?

Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10:837-852.

The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.

Journal Article > Study

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements.

Urban R, Paloumpi E, Rana N, Morgan J. Int J Clin Pharm. 2013;35:813-820.

Community pharmacists in England rarely receive post-discharge information regarding medication changes, which may increase the risk of medication discrepancies and adverse drug events.

Cases & Commentaries

Polypharmacy

  • Web M&M

B. Joseph Guglielmo, PharmD; May 2013

On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.

Tools/Toolkit > Toolkit

High-Alert Medication Modeling and Error-Reduction Scorecards (HAMMERS) for Community Pharmacies.

Horsham, PA: Institute for Safe Medication Practices; 2012.

This toolkit was developed to help community pharmacies identify risks associated with dispensing high-alert medications, assess how these risks may affect patients, and implement strategies to prevent errors.

Newspaper/Magazine Article

Prescription mistakes are rampant and under-reported.

LaGrone K. WPTV.com. April 30, 2012.

This news piece discusses pharmacy medication dispensing errors and describes how patients can help prevent them.

Book/Report

A Review of FDA’s Approach to Medical Product Shortages.

Silver Spring, MD: US Food and Drug Administration; October 31, 2011.

This report outlines the complex nature of drug shortages and suggests strategies to augment the FDA's efforts to address them.

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