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Search results for "Education and Training"

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Press Release/Announcement

FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering.

Silver Spring, MD: US Food and Drug Administration; April 9, 2019.

Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.

Journal Article > Study

An educational and audit tool to reduce prescribing error in intensive care.

Thomas AN, Boxall EM, Laha SK, Day AJ, Grundy D. Qual Saf Health Care. 2008;17:360-363.

This study developed and implemented an educational program that provided prescribing standards, formal education, and repeated feedback to reduce errors in practice.

Journal Article > Study

A prevalence study of errors in opioid prescribing in a large teaching hospital.

Davies ED, Schneider F, Childs S, et al. Int J Clin Pract. 2011;65:923-929.

This cross-sectional study found that more than one quarter of opioid prescriptions at a teaching hospital contained at least one error.

Journal Article > Study

Factors associated with medication errors in the pediatric emergency department.

Vilà-de-Muga M, Colom-Ferrer L, Gonzàlez-Herrero M, Luaces-Cubells C. Pediatr Emerg Care. 2011;27:290-294.

Prescribing errors in a pediatric emergency department were more frequent on weekends and at night, and residents committed errors more frequently than attending physicians.

Journal Article > Study

Medication error identification rates by pharmacy, medical, and nursing students.

Warholak TL, Queiruga C, Roush R, Phan H. Am J Pharm Educ. 2011;75:24.

This study found that pharmacy students identified more prescribing errors than medical and nursing students, perhaps due to their increased coursework and emphasis on medication safety.

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.

Book/Report

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.

Journal Article > Study

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

Medication prescribing errors are common in teaching hospitals. This study used critical incident debriefing to examine the underlying causes of why doctors—particularly trainees—make incorrect prescribing decisions. The team dynamic emerged as a significant factor in prescribing, with residents reporting being strongly influenced by other team members in both positive and negative ways. In particular, the authority gradient resulted in residents feeling unable to question senior physicians about prescribing decisions, but residents also reported receiving pressure from nurses to prescribe certain medications. Residents were also reluctant to change prescriptions written by colleagues for fear of creating team disharmony, even when they had concerns about the safety of the medication. While much research has focused on educational and technological solutions for prescribing errors, this study demonstrates a possible role for teamwork training.

Journal Article > Study

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.  

Medication errors are a common problem in pediatric outpatients, and high-alert medications such as opioid analgesics are a major cause of emergency department visits in both children and adults. This study evaluated the quality of analgesic prescriptions in patients being discharged from a pediatric teaching hospital. Most prescriptions contained at least one error, including frequent use of error-prone abbreviations and failure to use weight-based dosing, and 3% of prescriptions were judged to have the potential for serious patient harm. Computerized provider order entry (CPOE) has been advocated as a means of preventing medication errors in children, but in a prior study, CPOE actually failed to reduce dosing errors in children.

Cases & Commentaries

Sick and Pregnant

  • Web M&M

Shareen El-Ibiary, PharmD, BCPS; November 2008

A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.

Journal Article > Commentary

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.

Journal Article > Study

Reducing medication prescribing errors in a teaching hospital.

Garbutt J, Milligan PE, McNaughton C, et al. Jt Comm J Qual Patient Saf. 2008;34:528-536.

An educational intervention reduced prescribing errors by surgical residents but not medical residents.

Cases & Commentaries

Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad

  • Spotlight Case
  • Web M&M

Sumant Ranji, MD; April 2008

A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.

Journal Article > Study

Decreasing paediatric prescribing errors in a district general hospital.

Davey AL, Britland A, Naylor RJ. Qual Saf Health Care. 2008;17:146-149.

A prescribing tutorial for junior doctors successfully reduced medication prescribing errors in a children's hospital.

Newspaper/Magazine Article

Lack of standard dosing methods contributes to IV errors.

ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.

This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.

Newspaper/Magazine Article

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007;12:1-3.

This article discusses inappropriate prescribing of medication patches for acute pain management and provides strategies for minimizing problems associated with their use.

Audiovisual

Preventing dosage errors with Diastat AcuDial. 

Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.

This video segment warns about potential dosing errors for an epileptic seizure treatment due to equipment design and provides instructions to minimize user error.

Journal Article > Study

Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.

Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Pediatrics. 2006;118:e1124-e1129.

This study describes an effort to reduce adverse drug events (ADEs) at a pediatric tertiary care hospital through interventions targeting the clinical staff. These interventions included use of a Web-based tutorial on medication safety, a "zero-tolerance" policy whereby any medication errors would have to be rewritten, and feedback of individual data on prescribing error to clinicians. The intervention achieved impressive reductions in potential ADEs, defined as any incompletely written medication order, but did not document the incidence of ADEs resulting in patient harm. The baseline incidence of potential ADEs was also higher than that seen in prior research.

Newspaper/Magazine Article

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.

Newspaper/Magazine Article

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

This alert presents the risks involved with tablet splitting and outlines several recommendations for providers to increase safety.

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