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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.

Cases & Commentaries

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

  • Web M&M

Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

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.

Special or Theme Issue

Insulin Pens Devices.

Am J Health Syst Pharm. 2016;73(19 suppl 5);S1-S47.

As a high-alert medication, insulin has the potential to result in serious patient harm if administered incorrectly. Articles in this special issue discuss recommendations developed to address risks associated with pen injector practices and the results of an improvement initiative to enhance the safe use of insulin pens. Mentoring and safety culture are highlighted as areas that support improvements.

Journal Article > Commentary

Incorporating indications into medication ordering—time to enter the age of reason.

Schiff GD, Seoane-Vazquez E, Wright A. N Engl J Med. 2016;375:306-309.

Clear communication during medication prescribing can enhance safety. This commentary advocates for indications-based prescribing coupled with health information technology as a way to improve team communication, medication reconciliation, and patient education and compliance.

Journal Article > Commentary

Case report of a medication error: in the eye of the beholder.

Naunton M, Nor K, Bartholomaeus A, Thomas J, Kosari S. Medicine (Baltimore). 2016;95:e4186.

Look-alike drug names or packaging are known to contribute to medication errors. This case discussion reviews an error in the community setting involving a nonocular medication mistakenly administered as an eye drop due to look-alike packaging and recommends ways to improve storage and disposal processes to avoid similar incidents.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial.

Bhattacharya D, Aldus CF, Barton G, et al. Health Technol Assess. 2016;20:1-250.

Medication organization devices provide compartments to help sort patients' medications by days of the week and are thought to improve medication safety. Assessing patients age 75 and older who were prescribed three or more oral medications, this feasibility study found that medication adherence did not improve among those given medication organization devices compared to those using standard medication dispensing. The authors note that many potentially eligible participants were excluded because they already used such devices and suggest that future studies target a younger age range.

Journal Article > Study

Using simulation to improve first-year pharmacy students' ability to identify medication errors involving the top 100 prescription medications.

Atayee RS, Awdishu L, Namba J. Am J Pharm Educ. 2016;80:86.

Pharmacists can intercept prescription errors before they reach patients. This study found that an educational intervention that combined didactic lecture and simulation methods enhanced first-year pharmacy students' ability to identify prescribing errors. These results demonstrate the value of developing pharmacy education to improve patient safety.

Journal Article > Study

Partnered pharmacist charting on admission in the general medical and emergency short-stay unit—a cluster-randomised controlled trial in patients with complex medication regimens.

Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-418.

Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.

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.

Journal Article > Review

Medication safety systems and the important role of pharmacists.

Mansur JM. Drugs Aging. 2016;33:213-221.

Preventing adverse drug events is a major priority for accrediting and regulatory agencies. This review describes a framework for medication safety systems, including design considerations to integrate safety across the medication use process and unique roles for clinical pharmacists. Elements of the framework address risk awareness, barriers to error reporting, and the need to utilize performance improvement methods.

Journal Article > Commentary

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.

Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Audiovisual

Seven (potentially) deadly prescribing errors.

Graham LR, Scudder L, Stokowski L. Medscape Multispecialty. October 22, 2015.

Errors in the prescribing process can lead to adverse drug events. This slide set provides information about common problems in prescribing such as selecting the wrong drug in a drop-down menu, formulation mix-ups, alert fatigue, poor quality of data in health information systems, and use of ambiguous abbreviations.

Journal Article > Commentary

Hospice diagnosis: polypharmacy—a teachable moment.

Larson CK, Kao H. JAMA Intern Med. 2015;175:1750-1751.

Overprescribing can increase risk of dementia, particularly among older patients. This commentary describes an incident involving a patient with moderate dementia that worsened when opioids were prescribed following a fall. After a geriatrician evaluated the patient and suspected polypharmacy, the drugs were stopped, caregivers were educated about how to treat the patient, and the patient improved. Highlighting the importance of environmental interventions in treating this patient, the author reviews strategies to address neuropsychiatric symptoms of dementia.

Journal Article > Study

A medical resident–pharmacist collaboration improves the rate of medication reconciliation verification at discharge.

Caroff DA, Bittermann T, Leonard CE, Gibson GA, Myers JS. Jt Comm J Qual Patient Saf. 2015;41:457-461.

This pre-post study found that a standardized pharmacist review of patient medications prior to hospital discharge improved the accuracy of medication reconciliation, with fewer errors uncovered over time. This work adds to the body of evidence supporting pharmacist involvement in medication reconciliation across settings.

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 > Study

Pediatric emergency department discharge prescriptions requiring pharmacy clarification.

Caruso MC, Gittelman MA, Widecan ML, Luria JW. Pediatr Emerg Care. 2015;31:403-408.

This chart review study found that callbacks from retail pharmacies to a pediatric emergency department were usually related to insurance or clinically insignificant errors, but more than 10% were considered at least significant. These findings demonstrate the need for more robust decision support in electronic prescribing.

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