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Search results for "Active Errors"

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Special or Theme Issue

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.

Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Cases & Commentaries

The Empty Bag

  • Web M&M

Chris Vincent, PhD; December 2016

Admitted to the hospital for treatment of a hip fracture, an elderly woman with end-stage dementia was placed on the hospice service for comfort care. The physician ordered a morphine drip for better pain control. The nurse placed the normal saline, but not the morphine drip, on a pump. Due to the mistaken setup, the morphine flowed into the patient at uncontrolled rate.

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.

Cases & Commentaries

Inadvertent Use of More Potent Acid Leads to Burn

  • Web M&M

Howard I. Maibach, MD; January 2016

An attending physician recommended using acetic acid to evaluate a lesion on the perineum of a woman who had previously experienced a wart in the same area. The resident physician asked the medical assistant for acetic acid and unknowingly received trichloroacetic acid, which burned the patient's skin.

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.

Press Release/Announcement

Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. June 30, 2015.

Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.

Cases & Commentaries

Medication Mix-Up: From Bad to Worse

  • Web M&M

Amanda Wollitz, PharmD, and Michael O'Connor, PharmD, MS; March 2015

Admitted to the hospital with chest pain, headache, and accelerated hypertension, an older man with a history of chronic kidney disease and essential hypertension who had missed several days of his regular medications was to be started back on them gradually. One of his antihypertensive medications (minoxidil) was ordered via the EHR, but a vasopressor/antihypotensive medication with a similar name (midodrine) was dispensed. Fortunately, a nurse noticed the discrepancy before administration.

Newspaper/Magazine Article

FDA begins inquiry after death and illness from saline bags meant for training.

Tavernise S. New York Times. January 15, 2015.

This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.

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.

Newspaper/Magazine Article

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.

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.

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.

Journal Article > Study

Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.

White R, Cassano-Piché A, Fields A, Cheng R, Easty A. J Oncol Pharm Pract. 2014;20:40-46.

A fatal chemotherapy medication error prompted this thorough examination of ambulatory intravenous chemotherapy processes in Canada. This study uncovered potential preparation errors that were previously unrecognized and could lead to serious patient harms.

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.

Newspaper/Magazine Article

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.

This newsletter article reveals system failures that contribute to continued drug name confusion, even after authorities have been notified of the problem.

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

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.

Journal Article > Study

Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.

Moniz TT, Seger AC, Keohane CA, Seger DL, Bates DW, Rothschild JM. Am J Health Syst Pharm. 2011;68:158-163.

Dispensing errors in the community setting are a frequent source of concern despite greater adoption of computerized prescriber order entry (CPOE) and barcode technologies. This study added e-prescribing technology to an existing CPOE system and evaluated discrepancies between prescribers' orders and the dispensed prescription information. Investigators captured more than 11,000 prescriptions written in the control clinics and nearly 30,000 in the e-prescribing ones to compare rates before and after implementation. E-prescribing was associated with a statistically significant reduction in dispensing errors, by nearly half, compared with printing a prescription out of a CPOE system and then handing it to patients. The authors advocate for this feature as a meaningful intervention to improve medication safety. A past AHRQ WebM&M commentary discussed a dispensing error that originated from a poorly handwritten prescription.

Press Release/Announcement

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.

This announcement reveals a labeling change to reduce the potential for misadministration of a pain medication.

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