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Search results for "Active Errors"

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Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

This monthly selection of medication error reports discusses a mistake with chelation therapy agents due to similar acronym use, confusion of drugs similarly named in different countries, and inadequate information about changes to an existing drug.

Journal Article > Study

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.

Anticoagulants are considered high-risk medications due to their narrow therapeutic window and association with adverse drug events. This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent anticoagulation dosing errors and resultant harm to patients.

Cases & Commentaries

Consequences of Medical Overuse

  • Spotlight Case
  • CME/CEU
  • 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

Overdose risk in young children of women prescribed opioids.

Finkelstein Y, Macdonald EM, Gonzalez A, Sivilotti MLA, Mamdani MM, Juurlink DN; Canadian Drug Safety And Effectiveness Research Network (CDSERN). Pediatrics. 2017;139:e20162887.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.

Journal Article > Commentary

Inappropriate opioid dosing and prescribing for children: an unintended consequence of the clinical pain score?

Voepel-Lewis T, Malviya S, Tait AR. JAMA Pediatr. 2017;171:5-6.

Opioid prescribing is gaining attention as a high-risk activity in both general and pediatric care. This commentary explains how well-intentioned efforts to manage pain in children might have unintentionally contributed to the opioid epidemic. The authors suggest that policy approaches may help address the problem at the system level.

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 > Study

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

Cases & Commentaries

Complaints as Safety Surveillance

  • Web M&M

Jennifer Morris and Marie Bismark, MD; September 2016

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Cases & Commentaries

Wrong-Time Error With High-Alert Medication

  • Web M&M

Annie Yang, PharmD, and Lewis Nelson, MD; September 2016

Admitted for knee surgery, a man was given his medications at 10 PM, including oral dofetilide (an antiarrhythmic agent with a strict 12-hour dosing interval). In the electronic health record, "q12 hour" drugs are scheduled for 6 AM and 6 PM by default. Because the patient was scheduled to leave for the operating room before 6 AM, the nurse gave the dose at 4 AM. Preoperative ECG revealed he had severe QTc prolongation (putting him at risk for a fatal arrhythmia), and surgery was canceled.

Journal Article > Commentary

Access to prescription opioids—Primum Non Nocere: a teachable moment.

Tyler PD, Larochelle MR, Mafi JN. JAMA Inter Med. 2016;176:1251-1252.

Insufficient medication counseling and suboptimal prescribing practices contribute to misuse of opioids among patients. Describing a patient who became addicted to prescription opioids as a teenager after finding the medication at home, this commentary illustrates how current prescribing guidelines can address the opioid epidemic in the United States.

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.

Tools/Toolkit > Fact Sheet/FAQs

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

Horsham, PA: Institute of Safe Medication Practices; 2016.

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Tools/Toolkit > Fact Sheet/FAQs

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

Institute for Safe Medication Practices. June 2016.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall Man lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of Tall Man lettering to make their use safer.

Newspaper/Magazine Article

Do not let "Depo-" medications be a depot for mistakes.

ISMP Medication Safety Alert! Acute Care Edition. March 24, 2016;21:1-4.

Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.

Journal Article > Study

An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.

Olaiya A, Lurie B, Watt B, McDonald L, Greaves M, Watson HG. J Thromb Haemost. 2016;14:987-990.

Anticoagulant medications are known to be high-risk for adverse drug events. This study found that many physicians fail to recognize risks associated with direct oral anticoagulants or their effect on anticoagulation tests. These results raise concern for patient harm due to insufficient knowledge about these medications.

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 > Commentary

Strategies for flipping the script on opioid overprescribing.

Wright AP, Becker WC, Schiff GD. JAMA Intern Med. 2016;176:7-8.

Opioid misuse is at epidemic proportions in the United States. This commentary advocates for physicians who recognize that their patients are misusing opioids to carefully approach changes in treatment strategies. Providers should adjust their prescribing behavior, counseling skills, and use of electronic health records to determine an effective care plan to address the patient's pain.

Journal Article > Commentary

Two fatal cases of accidental intrathecal vincristine administration: learning from death events.

Chotsampancharoen T, Sripornsawan P, Wongchanchailert M. Chemotherapy. 2015;61:108-110.

Incorrectly administered vincristine can lead to serious adverse consequences. Discussing two incidents involving accidental intrathecal vincristine administration, this commentary describes how the health care organization implemented changes (including using different bags for drugs and label colors for syringes) following the first event and made further revisions when the second incident occurred 7 years later (such as ensuring drugs are delivered during different times and in certain settings).

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.

Cases & Commentaries

Amphotericin Toxicity

  • Web M&M

Jerod Nagel, PharmD, and Eric Nguyen; October 2015

A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.

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