Search results for "Information Professionals"

Look-alike and sound-alike medications increase the risk of adverse drug events. This retrospective study found that look-alike and sound-alike medications can be identified in an automated fashion by comparing a medication and its known look-alike and sound-alike medications to diagnostic codes at the point of computerized provider order entry. This is a promising strategy for preventing this type of prescribing error.

Diabetes medications are known to be high risk for adverse drug events. This case study reviews several patient safety measures for electronic prescribing for diabetes in outpatient care. Researchers describe an adverse drug event involving electronic prescribing of insulin and detail how the incident could have been prevented. Electronic prescribing is not currently standardized and may require using a trade name for medications, which may lead to prescribing errors. Adoption of the medication naming conventions put forth by the National Library of Medicine's RxNorm would prevent this vulnerability. Similarly, standardizing electronic prescribing orders for high-risk medications like insulin may reduce the risk of erroneously choosing a long-acting instead of short-acting insulin formulation, which can have life-threatening consequences. The authors advocate for using Universal Medication Schedule instructions and providing language-concordant labels to patients to support safe medication self-administration. They suggest that real-time, bidirectional communication between prescribers and pharmacists may improve safe prescribing. The authors conclude that recommended safety practices are not uniformly implemented in clinical practice and advocate for implementation research to ensure medication safety for outpatients with diabetes.

Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.

Chemotherapy administration has a well known potential for errors. This pre–post study found that implementation of an electronic health record–facilitated, pharmacist-led, standardized ordering and monitoring program for oral chemotherapy led to better identification of prescribing errors. This research adds to the evidence for the role of pharmacists in making cancer care safer.

Confusion due to look-alike and sound-alike medications are known to contribute to medication errors. Describing errors associated with a certain medication naming convention, this newsletter article offers recommendations to reduce risks related to these drugs, including labeling clarifications, storing medications separately, barcode scanning, and staff education.

A computerized clinical decision support system for inpatient glucose management resulted in fewer clinically significant episodes of abnormal blood sugars compared to a paper-based system. However, user deviations from the recommended computerized protocol were associated with episodes of hyperglycemia. A WebM&M commentary discusses a case in which misuse of a computerized glucose management system resulted in patient harm.

Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.

This quality improvement study to enhance the safety of chemotherapy was conducted at a tertiary care hospital in Pakistan. Investigators found that standardized chemotherapy orders within a computerized provider order entry system were associated with fewer medication errors as well as improved dispensing efficiency compared with the older, paper-based order system.

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.

This study was conducted using a trigger tool method in which all cases of naloxone administration in the emergency department were reviewed. Causes of iatrogenic opioid overdose included patient factors such as comorbid conditions, inappropriate prescribing practices such as coadministration of multiple opioid medications, and systems problems including suboptimal handoffs and lack of pharmacy oversight. These results clearly demonstrate the need for multimodal interventions that address the varied factors that contribute to opioid overdose in the emergency department. A recent AHRQ WebM&M commentary describes best practices for opioid prescribing.

This before-and-after study found that clinical decision support reduced medication errors (greater than maximum dose) for five high-alert medications. Changes in order patterns emerged following the alerts, but the authors did not identify patient harm associated with the system. This work supports the use of clinical decision support for high-risk medications.

Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.

Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Confusion between medications with names that appear or sound similar is a common cause of medication errors. This observational study sought to determine whether a computerized provider order entry system—with an alert that prompted providers to enter the indication when certain medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem list, or to cancel the order—identified drug name confusion errors. These alerts intercepted 1.4 drug name confusion errors per 1000 alerts. While authors recommend that these alerts be implemented to decrease medication errors, they suggest narrowing the number of medications selected to prompt alerts to reduce risk of alert fatigue. A previous AHRQ WebM&M commentary describes an incident involving a look-alike drug error and reviews strategies to enhance safety of medication selection.

Various technologies have been developed to reduce medication errors. Examining the research around implementation of these technologies, such as computerized provider order entry and bar-code medication administration, this review identifies their benefits and drawbacks on chemotherapy administration safety.

Chemotherapy is a notoriously high-risk medication. A chemotherapy medication prescribing error was responsible for one of the most infamous patient safety cases, the tragic death of Boston Globe reporter Betsy Lehman. Computerized provider order entry is thought to reduce prescribing errors, but it has not specifically been studied for chemotherapy. In this study, implementation of standardized templates for chemotherapy ordering was associated with a significant reduction in prescribing errors as well as administration errors. While this study is promising, a recent AHRQ WebM&M commentary illustrates that even standardized ordering protocols cannot entirely prevent chemotherapy errors.

This newsletter article relates three incidents involving high-alert medication errors and describes how automated warnings could have prevented them.

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.

This study highlights the role of alert fatigue and provider overrides in contributing to warfarin-related adverse drug events.

Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.

The vast majority of warnings about warfarin (a commonly prescribed anticoagulant) generated by a bar-code medication administration system were clinically insignificant.