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Search results for "Active Errors"

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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

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

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.

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 > 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.

Journal Article > Review

Interventions for reducing medication errors in children in hospital.

Maaskant JM, Vermeulen H, Apampa B, et al. Cochrane Database Syst Rev. 2015;3:CD006208.

Exploring the literature on efforts to reduce medication errors in hospitalized children, this systematic review examined five interventions, including introduction of computerized provider order entry systems, clinical pharmacist participation in the frontline care team, and implementation of barcode medication administration systems. Although the interventions showed some success, none of the studies found a significant reduction in patient harm.

Journal Article > Study

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

Shaw RE, Litman RS. Jt Comm J Qual Patient Saf. 2014;40:471-475.

In 2010, the Anesthesia Patient Safety Foundation recommended that hospital pharmacies supply premixed solutions or prefilled syringes of commonly used anesthetic medications. Despite this recommendation, this convenience sample of 34 children's hospitals across the United States found that the majority of medications administered by anesthesiologists in 2012 were still prepared by the provider at the bedside.

Audiovisual

Hospitals put pharmacists in the ER to cut medication errors.

Silverman L. Morning Edition. National Public Radio. June 9, 2014.

This radio segment discusses the experience of a pediatric medical center that hired pharmacists for its emergency department to review medication orders before the medicine is dispensed and administered in an effort to prevent medication errors.

Journal Article > Study

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2013.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2014;71:924-942.

This national survey of inpatient pharmacy directors found that most hospitals maintain strict control of medication formularies, and direct pharmacist involvement in inpatient care is growing. Electronic prescribing was reported to occur in the majority of outpatient clinics and hospitals. A past AHRQ WebM&M perspective discussed how expanding the role of pharmacists has the potential to improve safety.

Journal Article > Review

Using pharmacists to optimize patient outcomes and costs in the ED.

Jacknin G, Nakamura T, Smally AJ, Ratzan RM. Am J Emerg Med. 2014;32:673-677.

Exploring factors that increase risk of medication-related errors in the emergency department, this review describes the benefits of incorporating clinical pharmacists in the frontline care team, including real-time monitoring, discussion, and education about medication prescribing and use of substitute drugs.

Journal Article > Study

The effect of a clinical pharmacist-led training programme on intravenous medication errors: a controlled before and after study.

Nguyen HT, Pham HT, Vo DK, et al. BMJ Qual Saf. 2014;23:319-324.

An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).

Cases & Commentaries

Pocket Syringe Swap

  • Web M&M

John C. Kulli, MD; May 2011

A surgery fellow put two syringes in his pocket: one containing leftover anesthetic and one with agents to reverse it. When it came time to reverse the neuromuscular block, he administered the anesthetic by mistake.

Newspaper/Magazine Article

Medication errors in the emergency department: need for pharmacy involvement?

PA-PSRS Patient Saf Advis. March 2011;8:1-7.

This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvement as a strategy to reduce risks.

Tools/Toolkit > Fact Sheet/FAQs

Preventing Medication Errors: A $21 Billion Opportunity.

  • Classic

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

This briefing sheet reviews the opportunities, solutions, and drivers for medication safety improvements.

Journal Article > Study

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

This study describes how implementation of a computerized provider order entry system reduced errors associated with prescribing oral chemotherapy.

Journal Article > Study

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Drug Saf. 2010;33:1027-1044.

Prescribing errors remained relatively common at hospital discharge in this study, despite the presence of computerized provider order entry and the use of pharmacists to review discharge medication orders.

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

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.

Journal Article > Study

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

This study reports on a quality improvement effort to eliminate errors due to look-alike, sound-alike medications.

Journal Article > Study

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

In this direct observation study, emergency department pharmacists identified approximately one actual or potential medication error per 13 patients.

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