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Search results for "Policies and Operations"
- Policies and Operations
Journal Article > Review
Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. July 30, 2019;(61):1-5.
Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.
Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Journal Article > Study
Organizational conditions for engagement in quality and safety improvement: a longitudinal qualitative study of community pharmacies.
Phipps DL, Jones CEL, Parker D, Ashcroft DM. BMC Health Serv Res. 2018;18:783.
In this qualitative study, researchers followed the progress of the improvement work taken on by 10 English community pharmacies that participated in improvement workshops over a 1-year period. Using a behavioral change framework, they were able to describe the pharmacies' progress in their activities as well as identify particular organizational factors facilitating improvement work.
Mix-ups between epidural analgesia and IV antibiotics in labor and delivery units continue to cause harm.
ISMP Medication Safety Alert! Acute Care Edition. October 4, 2018;23:1-4.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Journal Article > Government Resource
García MC, Dodek AB, Kowalski T, et al. MMWR Morb Mortal Wkly Rep. 2016;65:1125-1131.
Adverse drug events related to opioid medications are a significant patient safety concern. This analysis of insurer claims data demonstrated that changing opioid prescribing requirements, including implementing patient–provider agreements, requiring prior authorization, and enforcing quantity limits, led to a decline in opioid prescribing. The authors recommend that insurers implement policies from the Centers for Disease Control and Prevention opioid guidelines to improve safety.
Journal Article > Study
Wakefield DS, Wakefield BJ, Despins L, et al. Jt Comm J Qual Patient Saf. 2012;38:24-33.
Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.
Landro L. Wall Street Journal. March 5, 2008:D1.
This article reports on new policies and procedures adopted by hospitals to prevent errors in the use of high-alert medications, such as heparin.