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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
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Journal Article > Study

Underlying risk factors for prescribing errors in long-term aged care: a qualitative study.

Tariq A, Georgiou A, Raban M, Baysari MT, Westbrook J. BMJ Qual Saf. 2016;25:704-715.

This qualitative study of medication prescribing practices at long-term care facilities uncovered multiple safety hazards, including inadequate handoffs, insufficient information flow, and lack of a robust safety culture. The results suggest that both systems approaches and team training are needed to improve medication safety in long-term care facilities.

Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This cross-sectional analysis sought to determine how a punitive work environment, poor feedback about errors, and inadequate preventive processes affect near-miss reporting by hospital pharmacists. Using data from the AHRQ Hospital Survey of Patient Safety Culture, researchers found that pharmacists who believed error prevention procedures and error feedback to be insufficient were less likely to report near misses. A work culture in which individuals are blamed for errors was also tied to less near-miss reporting, similar to other studies of safety culture. This study underscores the consistent finding that frontline health care personnel are more likely to participate in safety efforts when they perceive that their workplace is receptive to error reporting and develops interventions to address concerns raised. A previous AHRQ WebM&M perspective explores the evidence on safety culture over the past decade.

Audiovisual > Audiovisual Presentation

Medication Safety Certificate Program.

American Society of Health-System Pharmacists and Institute for Safe Medication Practices.

Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.

Journal Article > Study

Incident and long-term opioid therapy among patients with psychiatric conditions and medications: a national study of commercial health care claims.

Quinn PD, Hur K, Chang Z, et al. Pain. 2017;158:140-148.

Opioid medications are associated with an increased risk of adverse drug events, including overdose. Certain populations may be at greater risk for adverse outcomes from opioids and may be more likely to receive them. This study looked at health insurance claims data for more than 10 million patients who filled opioid prescriptions. Researchers found that those with underlying psychiatric and behavioral conditions (including opioid and nonopioid substance use disorders) were more likely to receive long-term opioid therapy than patients without such conditions.

Journal Article > Commentary

Lost in translation: medication labeling for immigrant families.

Smith MCJ, Yin HS, Sanders LM. J Am Pharm Assoc (2003). 2016;56:677-679.

Non–English-speaking patients face particular challenges associated with health literacy. This commentary highlights how pharmacists have a greater role in health care decisions in Latin American nations than in the United States. The authors describe why inconsistent and incomplete application of policies in US pharmacies contributes to risks and suggest prescription and medication delivery processes be altered to address this weakness.

Journal Article > Study

The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy.

Battis B, Clifford L, Huq M, Pejoro E, Mambourg S. J Oncol Pharm Pract. 2016 Oct 12; [Epub ahead of print].

Oral chemotherapy regimens are complex and may lead to severe adverse drug events. In this pilot study, nearly half of patients enrolled in a pharmacist-run oral chemotherapy monitoring clinic experienced a medication-related problem. This finding is consistent with prior studies that demonstrated pharmacist oversight improves safety of oral chemotherapy.

Book/Report

ISMP Guidelines for Safe Preparation of Compounded Sterile Preparations.

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

This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety.

Journal Article > Commentary

Incorporating indications into medication ordering—time to enter the age of reason.

Schiff GD, Seoane-Vazquez E, Wright A. N Engl J Med. 2016;375:306-309.

Clear communication during medication prescribing can enhance safety. This commentary advocates for indications-based prescribing coupled with health information technology as a way to improve team communication, medication reconciliation, and patient education and compliance.

Journal Article > Study

An insurer's care transition program emphasizes medication reconciliation, reduces readmissions and costs.

Polinski JM, Moore JM, Kyrychenko P, et al. Health Aff (Millwood). 2016;35:1222-1229.

This intervention study provided pharmacist support to perform medication reconciliation and care coordination for patients discharged from the hospital. Compared to similar-risk patients who did not receive the intervention, those who had medication reconciliation by pharmacists were less likely to be readmitted to the hospital. These results add to the existing literature supporting the utility of pharmacist-led care transition interventions.

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.

Journal Article > Study

Impact of pharmacist-provided medication therapy management on healthcare quality and utilization in recently discharged elderly patients.

Haag JD, Davis AZ, Hoel RW, et al. Am Health Drug Benefits. 2016;9:259-268.

Postdischarge pharmacist medication counseling has been shown to prevent readmissions. This randomized controlled trial of pharmacist-delivered telephone medication counseling did not show any difference in appropriateness of medication use. The authors noted the high frequency of inappropriate medication use overall.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

Safe implementation of standard concentration infusions in paediatric intensive care.

Arenas-López S, Stanley IM, Tunstell P, et al. J Pharm Pharmacol. 2017;69:529-536.

Pediatric medication safety is particularly challenging due to complexity around weight-based dosing. According to a retrospective study in a pediatric intensive care unit, most morphine-related medication administration errors could have been prevented with technology interventions such as barcode medication administration. The authors advocate for implementing standardized morphine infusions to improve safety.

Journal Article > Study

Medication sharing, storage, and disposal practices for opioid medications among US adults.

Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. JAMA Intern Med. 2016;176:1027-1029.

The prescription opioid epidemic is one of the most pressing current patient safety issues, resulting in thousands of deaths yearly. This survey of patients who used prescription opioids in the past year found that more than 20% had shared their medications with someone else, and nearly half had never received information on safe storage or disposal of these medications. The Centers for Disease Control and Prevention recently published guidelines on safe opioid prescribing.

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 > Study

Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program.

Zemaitis CT, Morris G, Cabie M, Abdelghany O, Lee L. Hosp Pharm. 2016;51:468-473.

Adverse events following hospital discharge can lead to costly hospital readmissions. This study demonstrated a modest decrease in readmissions following implementation of pharmacist-led medication reconciliation and postdischarge telephone calls. These results are consistent with prior studies that determined pharmacist support can help reduce readmissions.

Journal Article > Study

Utilization of pharmacy technicians to increase the accuracy of patient medication histories obtained in the emergency department.

Rubin EC, Pisupati R, Nerenberg SF. Hosp Pharm. 2016;51:396-404.

This retrospective study found that pharmacy technicians were able to collect a more accurate medication list for patients in the emergency department compared to the usual medication list obtained by other personnel. This finding suggests that better integration of the pharmacy team into emergency care could improve patient safety, consistent with previous studies investigating the role of pharmacists in emergency departments.

Web Resource > Multi-use Website

Standardize 4 Safety.

American Society of Health-System Pharmacists.

Standardization has been highlighted as a way to improve safety in surgery, care transitions, and medication administration. This initiative seeks to develop consensus guidelines and a set of standard concentrations to reduce errors associated with concentrations and dosing of liquid medications. The process for submitting comments on the first set of materials is open.

Journal Article > Study

A cross-sectional analysis investigating organizational factors that influence near-miss error reporting among hospital pharmacists.

Patterson ME, Pace HA. J Patient Saf. 2016;12:114-117.

This analysis of data from the AHRQ Hospital Survey on Patient Safety Culture found that pharmacists who perceived insufficient feedback after voluntarily reporting an error were less likely to report a near miss error. Failure to provide timely feedback to those who report an error is a recognized limitation of most existing voluntary reporting systems.

Journal Article > Study

Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.

Schroeder SR, Salomon MM, Galanter WL, et al. BMJ Qual Saf. 2017;26:395-407.

Look-alike and sound-alike drug names are a concerning source of confusion and medication errors. Although drug names currently undergo tests to assess their potential for confusion prior to approval, these tests have not reliably predicted real-world error rates. This study describes the development and validation of four drug name memory and perception laboratory tests. Eighty participants completed the tests and their results were analyzed against actual errors in two large outpatient pharmacy chains. The laboratory tests performed very well, demonstrating a strong association between drug name confusion errors seen during testing and those observed in real-world experience. The authors suggest that regulators and drug companies consider using these tests prior to approval of new drug names.

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