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Search results for "Active Errors"
- Active Errors
- Anticoagulants
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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
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.
Cases & Commentaries
Dual Therapy Debacle
- Web M&M
Steven R. Kayser, PharmD; September 2015
Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.
Legislation/Regulation
Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.
Heparin is a high-alert anticoagulant that has been associated with patient harm due to issues with administration and contamination. This draft guidance seeks to engage insights from the field to help improve labeling practices. The deadline for officially submitting comments was October 7, 2015.
Cases & Commentaries
New Oral Anticoagulants
- Spotlight Case
- Web M&M
Margaret C. Fang, MD, MPH; December 2013
Two days after knee replacement surgery, a woman with a history of deep venous thrombosis receiving pain control via epidural catheter was restarted on her outpatient dose of rivaroxaban (a newer oral anticoagulant). Although the pain service fellow scanned the medication list for traditional anticoagulants, he did not notice the patient was taking rivaroxaban before removing the epidural catheter, placing the patient at very high risk for bleeding.
Journal Article > Study
Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. J Healthc Risk Manag. 2013;33:33-43.
Patients in nursing homes are generally elderly, chronically ill, and take multiple medications, which places them at higher risk for medication errors. The state of North Carolina maintains a mandatory medication error reporting system for all nursing homes. This study analyzed data from this system to characterize errors due to anticoagulant drugs (which are considered high-risk medications). Errors were found to be common and harmful, often due to inadequate monitoring to ensure appropriate drug dosing. The authors recommend several potential solutions, but any interventions will likely also have to address the fact that safety culture in nursing homes is generally poor. An AHRQ WebM&M commentary discusses a preventable error due to inadequate monitoring of the anticoagulant warfarin at a nursing home, and an AHRQ WebM&M perspective explores the difficult problem of ensuring medication safety in nursing facilities.
Newspaper/Magazine Article
MGH faces suit over drug error that killed woman.
Valencia MJ. Boston Globe. March 10, 2011.
This newspaper article reports on a fatal medication error involving an anticoagulant overdose.
Journal Article > Study
Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.
- Classic
Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.
Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.
Newspaper/Magazine Article
Dennis Quaid's Quest.
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.
Journal Article > Study
Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.
Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.
Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.
Cases & Commentaries
Anticoagulation: Held Too Long
- Web M&M
Andrew S. Dunn, MD; April 2010
An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.
Newspaper/Magazine Article
Latest heparin fatality speaks loudly—what have you done to stop the bleeding?
ISMP Medication Safety Alert! April 8, 2010;15:1-3.
Detailing a recent lethal overdose of heparin, this piece describes common risks and offers suggestions to improve the safety of heparin administration.
Journal Article > Study
Error in body weight estimation leads to inadequate parenteral anticoagulation.
Dos Reis Macedo LG, de Oliveira L, Pintão MC, Garcia AA, Pazin-Filho A. Am J Emerg Med. 2011;29:613-617.
Inadequate dosing of anticoagulant medications was common in the emergency department due to inaccurate estimation of body weight.
Audiovisual
Nebraska Medical Center investigates staff after girl's death.
Luby R. KETV. Omaha, NE. March 31, 2010.
This news piece focuses on a heparin overdose that resulted in the death of a toddler.
Clinical Guideline
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.
- Classic
Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Journal Article > Study
Medication error reporting in nursing homes: identifying targets for patient safety improvement.
Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.
North Carolina law requires all nursing homes to report medication errors, as discussed in a prior article. Analysis of medication error reports submitted to this Web-based error reporting system revealed that most of the serious errors occurred during evening shifts and involved drugs given to the wrong patient.
Journal Article > Commentary
Dealing honestly with an honest mistake.
Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.
This case report describes a near miss involving a potential heparin overdose and discusses what physicians should tell patients in similar circumstances.
Journal Article > Study
Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.
Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.
Newspaper/Magazine Article
Collaboration focused on priority issues promotes safety.
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
Reporting that recalled medications were found in hospital pharmacies, this article describes recommendations to improve the process for removing recalled products.