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Search results for "Information Professionals"

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Journal Article > Study

Pharmacist–physician communications in a highly computerised hospital: sign-off and action of electronic review messages.

Pontefract SK, Hodson J, Marriott JF, Redwood S, Coleman JJ. PLoS One. 2016;11:e0160075.

Although electronic health records (EHRs) with computerized provider order entry are known to improve medication safety, experts have raised concerns that EHRs adversely affect interprofessional communication by reducing personal interactions among providers. This study examined unidirectional computerized messages from pharmacists and physicians within the EHR. Investigators found that less than half of messages from pharmacists were acknowledged by the prescribing physicians. Among the messages in which pharmacists requested a specific action, physicians completed the action about one-third of the time. Messages were more likely to be acknowledged and acted upon when pharmacists and physicians had an existing working relationship. The authors suggest that EHRs should be better designed to foster interprofessional collaboration. A PSNet perspective highlighted the role of pharmacists in interprofessional care and safety.

Journal Article > Study

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

Her QL, Amato MG, Seger DL, et al. J Am Med Inform Assoc. 2016;23:924-933.

Users often bypass alerts meant to enhance the safety of medication ordering and dispensing technologies. This observational study at a large academic medical center found approximately one in five nonformulary medication alerts are inappropriately overridden. The authors suggest strategies that future research should examine for improving the design of nonformulary alerts.

Journal Article > Study

Comparison of medication safety systems in critical access hospitals: combined analysis of two studies.

Cochran GL, Barrett RS, Horn SD. Am J Health Syst Pharm. 2016;73:1167-1173.

Medication errors are a well-recognized source of preventable patient harm and result from mistakes made during medication prescribing, transcribing, dispensing, and administration processes. This study looked at the impact of several factors on reducing medication errors in critical access hospitals. Investigators found that dispensing by an onsite pharmacist and the use of barcode technology for administration were both associated with a statistically significant reduction in medication errors.

Journal Article > Study

Impact of computerized physician order entry alerts on prescribing in older patients.

Lester PE, Rios-Rojas L, Islam S, Fazzari MJ, Gomolin IH. Drugs Aging. 2015;32:227-233.

Older patients are particularly vulnerable to medication errors, with certain high-risk medications accounting for a large proportion of adverse drug events in these patients. This study evaluated the effect of warnings within a computerized provider order entry (CPOE) system targeting prescribing of unsafe medications to patients aged 65 years and older. The warnings resulted in a significant decrease in prescribing of two of the three medications targeted over a 3-year period. The authors note that there were readily available, safer alternatives for those medications, but not for the drug which continued to be prescribed. Also, prescription rates of all three medications were unchanged in younger patients, indicating that the tailored nature of the alerts played a role in their effectiveness. While clinical decision support within CPOE does have some effect on safe prescribing, the use of computerized warnings of this type must be balanced against the very real possibility that alert fatigue may develop as a result.

Journal Article > Study

Influence of a systems-based approach to prescribing errors in a pediatric resident clinic.

Condren M, Honey BL, Carter SM, et al. Acad Pediatr. 2014;14:485-490.

This study compared an outpatient pediatric clinic with pharmacist prescription medication review and electronic health record customization to one without such systems in place. The clinic with workflow and technology to prevent adverse drug events experienced fewer errors, adding to the evidence that sociotechnical approaches are needed to improve medication safety.

Journal Article > Study

Using Lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose."

Ching JM, Williams BL, Idemoto LM, Blackmore CC. Jt Comm J Qual Patient Saf. 2014;40:341-350.

This study highlights the use of Lean methodologies to facilitate implementation of barcode medication administration (BCMA) for hospitalized patients at Virginia Mason Medical Center. The introduction of BCMA led to significantly fewer medication errors. The concepts presented may be helpful for organizations employing new health technologies.

Journal Article > Study

Medication safety and knowledge-based functions: a stepwise approach against information overload.

Patapovas A, Dormann H, Sedlmayr B, et al. Br J Clin Pharmacol. 2013;76(supp 1):14-24.

An electronic clinical decision support system for prescribing in the emergency department used tiered alerts with higher and lower urgency information in order to avoid alert fatigue.

Journal Article > Study

Drug related problems and pharmacist interventions in a geriatric unit employing electronic prescribing.

Raimbault-Chupin M, Spiesser-Robelet L, Guir V, et al. Int J Clin Pharm. 2013;35:847-853.

Potential adverse drug events (ADEs) continued to occur on a geriatric hospital ward despite use of computerized provider order entry. Student pharmacists were able to identify potential ADEs and implement preventive measures.

Journal Article > Study

Do drug interaction alerts between a chemotherapy order-entry system and an electronic medical record affect clinician behavior?

Weingart SN, Zhu J, Young-Hong J, Vermilya HB, Hassett M. J Oncol Pharm Pract. 2014;20:163-171.

In this study, computer alerts for possible drug interactions between chemotherapy orders and ambulatory medications sometimes led physicians to change their orders, which could prevent adverse drug events in these vulnerable patients.

Journal Article > Government Resource

Adverse drug events in surgical patients: an observational multicentre study.

de Boer M, Boeker EB, Ramrattan MA, et al. Int J Clin Pharm. 2013;35:744-752.

This study found a remarkably high incidence of preventable medication errors in surgical patients, despite universal use of computerized provider order entry.

Journal Article > Study

Clinical pharmacy interventions in paediatric electronic prescriptions.

Maat B, Au YS, Bollen CW, van Vught AJ, Egberts TC, Rademaker CM. Arch Dis Child. 2013;98:222-227.

Pharmacists frequently had to intervene to prevent medication errors in a children's hospital, despite the presence of a computerized provider order entry system.

Newspaper/Magazine Article

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

ISMP Medication Safety Alert! Acute Care Edition. June 28, 2012;17:1-3.

This newsletter article discusses an error involving a parenteral nutrition order and recommends strategies to prevent errors associated with automated compounding devices and order entry software.

Journal Article > Study

Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands.

Dequito AB, Mol PG, van Doormaal JE, et al. Drug Saf. 2011;34:1089-1100.

More than half of hospitalized patients in this Dutch study experienced an adverse drug event, most of which were not preventable and had minimal clinical consequences.

Newspaper/Magazine Article

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

This news article reviews actual and potential medication errors submitted to the Institute for Safe Medication Practices in 2010 and provides recommendations to address them.

Journal Article > Study

Medicines reconciliation using a shared electronic health care record.

Moore P, Armitage G, Wright J, Dobrzanski S, Ansari N, Hammond I, Scally A. J Patient Saf. 2011;7:147-153.

Achieving medication reconciliation continues to present significant challenges, despite existing guidelines and its demonstrated impact on patient safety. Electronic health records (EHRs) and related tools have long been touted as solutions to bolster reconciliation safety. This study evaluated whether an EHR shared between outpatient and inpatient providers could reduce suspected medication discrepancies. Although errors were reduced, significant discrepancies persisted among various forms of reconciliation, including differences between what was in the record and what patients actually reported taking. Problems included outdated or incomplete medication information, incorrect information provided by patients, or mismatched information between the different sources. The authors argue that EHRs, as an added information vehicle, may help reduce reconciliation errors, but they caution that EHRs are only a tool (and not in themselves a solution) for safer reconciliation. A past AHRQ WebM&M commentary discussed whose job it is to assure safe medication reconciliation.

Journal Article > Study

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

Hartel MJ, Staub LP, Röder C, Eggli S. BMC Health Serv Res. 2011;11:199.

Illegible handwriting has been cited as a major factor in several high-profile medication prescribing errors. This Swiss study found that the majority of handwritten prescriptions were considered "bad or unreadable," and more than half of the medication errors in this study were ascribed to transcribing errors attributable to poor handwriting.

Journal Article > Study

Developing a programme for medication reconciliation at the time of admission into hospital.

Manzorro AG, Zoni AC, Rieiro CR, et al. Int J Clin Pharm. 2011;33:603-609. 

Implementation of an electronic medication reconciliation tool reduced drug discrepancies at the time of hospital admission.

Newspaper/Magazine Article

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

This piece describes how reliability science can be applied to barcoded medication administration (BCMA) and discusses the results of one hospital's AHRQ-funded BCMA project.

Journal Article > Study

Improving the usability of intravenous medication labels to support safe medication delivery.

Bauer DT, Guerlain S. Int J Ind Ergon. 2011;41:394-399.

A human factors engineering approach to improving medication label safety was hampered by numerous issues, ranging from regulatory requirements to limitations of existing information technology systems.

Journal Article > Study

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. J Hosp Med. 2011;6:329-337.

This study identified unreliable sources of information and competing tasks as key barriers to safe medication reconciliation.

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