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Search results for "Active Errors"

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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.

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.

Journal Article > Study

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients.

Hsu CC, Chou CY, Chou CL, et al. PLoS One. 2014;9:e114359.

Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.

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.

Cases & Commentaries

May I Have Another?—Medication Error

  • Web M&M

Michael Wolf, PhD, MPH; June 2014

A man admitted to the hospital for his first seizure was found to have been taking up to 10 tablets of 10 mg zolpidem per night (an unsafe dose) to fall asleep and had recently run out. The instructions on the medication label had stated: "If ineffective, take another."

Cases & Commentaries

Discontinued Medications: Are They Really Discontinued?

  • Web M&M

Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA; May 2014

An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.

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.

Cases & Commentaries

Clostridium Difficile Relapse Secondary to Medication Access Issue

  • Web M&M

Paul C. Walker, PharmD, and Jerod Nagel, PharmD; April 2014

Following a hospitalization for Clostridium Difficile–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.

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 > Commentary

Doing right by our patients when things go wrong in the ambulatory setting.

Schiff G, Griswold P, Ellis BR, et al. Jt Comm J Qual Patient Saf. 2014;40:91-96.

This commentary describes the partnerships and consensus efforts involved in the PROMISES Project to promote communication and support error disclosure in the ambulatory setting. The authors review a plan to disseminate and assess the impact of the initiative and its associated tools.

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.

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.

Journal Article > Study

Electronic prescribing within an electronic health record reduces ambulatory prescribing errors.

Abramson EL, Barrón Y, Quaresimo J, Kaushal R. Jt Comm J Qual Patient Saf. 2011;37:470-478.

This community-based study found a significant reduction in medication prescribing errors after introduction of a computerized provider order entry system, compared with providers who continued to use paper-based prescriptions. Prescribing errors are a primary patient safety concern in ambulatory care.

Journal Article > Study

Do remote community telepharmacies have higher medication error rates than traditional community pharmacies? Evidence from the North Dakota Telepharmacy Project.

Friesner DL, Scott DM, Rathke AM, Peterson CD, Anderson HC. J Am Pharm Assoc. 2011;51:580-590.

This study reported a lower overall medication error rate for telepharmacy sites compared with traditional pharmacies.

Journal Article > Study

Errors associated with outpatient computerized prescribing systems.

  • Classic

Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-773.

Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.

Tools/Toolkit > Fact Sheet/FAQs

Ten Tips to Prevent an Accidental Overdose.

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

This flyer provides tips to help prevent consumer medication errors.

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