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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Tall Man lettering and potential prescription errors: a time series analysis of 42 children's hospitals in the USA over 9 years.

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Zhong W, Feinstein JA, Patel NS, Dai D, Feudtner C. BMJ Qual Saf. 2016;25:233-240.

Even in the era of electronic prescribing, look-alike and sound-alike drug names remain a safety vulnerability. In 2007, the Food and Drug Administration adopted Tall Man lettering, in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication (e.g., DOPamine; DOBUTamine). Despite widespread use of Tall Man lettering, it is unclear whether this strategy reduces errors. In this interrupted time series analysis, investigators pre-specified 12 look-alike, sound-alike drug errors in pediatric medication use and examined whether the frequency of these errors changed after Tall Man lettering was introduced. Although such errors were rare to begin with, they found no reduction after implementation of Tall Man lettering. This finding suggests that other interventions should be explored to avoid look-alike and sound-alike drug errors. This research also demonstrates the importance of evaluating safety interventions, which may have minimal impact despite face validity.

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

Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications.

Graudins LV, Ingram C, Smith BT, Ewing WJ, Vandevreede M. Int J Qual Health Care. 2015;27:67-74.

Omitted or delayed dosing of medications is an aspect of missed nursing care in inpatient settings. This quality improvement study describes an audit and feedback tool to ensure timely medication administration in hospitals. This type of standardized work and feedback, influenced by human factors engineering, has been applied to many patient safety programs.

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.

Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

Special or Theme Issue

The safety and quality of health care: where are we now?

Med J Aust. 2006;184:S37-S72.

This special issue includes numerous articles reviewing the activities and successes of the patient safety movement outside the United States.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017 Apr 21; [Epub ahead of print].

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

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.

Journal Article > Commentary

Standardizing concentrations of adult drug infusions in Indiana.

Walroth TA, Dossett HA, Doolin M, et al. Am J Health Syst Pharm. 2017;74:491-497.

Standardizing drug concentrations addresses a medication safety concern for both adult and pediatric inpatients. This commentary describes a state-wide consensus project that reconciled existing lists of adult IV drug concentrations to develop a final list of 26 IV concentrations to reduce risks of medication errors.

Journal Article > Government Resource

Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.

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Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.

Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.

Journal Article > Commentary

Responsible e-prescribing needs e-discontinuation.

Fischer S, Rose A. JAMA. 2017;317:469-470.

E-prescribing is a key strategy to improve medication safety by addressing illegible prescriptions, order omissions, and dosage confusion. However, there have been unintended consequences such as the inability to discontinue medications ordered electronically. This commentary reviews problems associated with this unintended consequence and suggests that enabling electronic cancellation of prescriptions can help address the issue. A WebM&M commentary discussed a case involving an electronic prescribing error.

Perspectives on Safety > Annual Perspective

Patient Safety and Opioid Medications

with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2016

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.

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.

Newspaper/Magazine Article

Prescribing errors that cause harm.

Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.

Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, this article recommends strategies to reduce risks associated with prescribing, including use of computerized provider order entry systems and standard order sets.

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 > Government Resource

Declines in opioid prescribing after a private insurer policy change—Massachusetts, 2011–2015.

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 > Commentary

Using computerized prescriber order entry to limit overrides from automated dispensing cabinets.

Drake E, Srinivas P, Trujillo T. Am J Health Syst Pharm. 2016;73:1033-1035.

Automated dispensing cabinets have been adopted in hospitals to enhance medication safety. These drug dispensing systems enable override functions so that nurses can access medications without pharmacist verification to ensure timeliness, but this workaround requires a reliable process to reduce the potential for errors. This commentary discusses how one hospital designed an oversight process using computerized provider order entry to increase the safety of this practice.

Journal Article > Study

Hospital prescribing of opioids to Medicare beneficiaries.

Jena AB, Goldman D, Karaca-Mandic P. JAMA Intern Med. 2016;176:990-997.

Misuse of prescription opioids represents a serious patient safety issue. In this study, investigators examined opioid prescribing to Medicare beneficiaries upon hospital discharge. They found that new opioid use was common after discharge and that prescribing rates varied widely across hospitals.

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.

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