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Approach to Improving Safety
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Search results for "Ordering/Prescribing Errors"

421 - 440 of 442 results
  • Ordering/Prescribing Errors
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Journal Article > Study

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

Pugh MJ, Fincke BG, Bierman AS, et al. J Am Geriatr Soc. 2005;53:1282-1289.

The authors identified inappropriate prescribing for geriatric patients and suggest interventions targeted for specific types of medications.

Journal Article > Study

Review of the Australian Incident Monitoring System.

Spigelman AD, Swan J. ANZ J Surg. 2005;75:657-661.

The authors surveyed users of the Australian Incident Monitoring System (AIMS) to determine its value for organizing and learning from data, promoting a safety culture, and increasing awareness of patient safety.

Journal Article > Commentary

Comprehensive analysis of a medication dosing error related to CPOE.

Horsky J, Kuperman GJ, Patel VL. J Am Med Inform Assoc. 2005;12:377-382.

This case study analyzes a potassium chloride (KCl) dosing error in a system using computerized provider order entry (CPOE). The authors identified problems related to screen results, usability, training, and others. They use their findings to suggest improvements in their hospital's CPOE system and to analyze CPOE system–related errors more generally.

Newspaper/Magazine Article

Drug name confusion: preventing medication errors.

Rados C. FDA Consum. 2005;39:35-37.

This article reports on problems with drug names, the naming process for medications, and both industry and consumer actions that can minimize misunderstandings.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

This monthly selection of medication error reports provides examples from the field of potential errors and helpful tips on how to avoid similar mistakes.

Cases & Commentaries

Surprise Wire

  • Web M&M

Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc; July-August 2005

A nurse preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement (1 week earlier) still in the patient's leg vein.

Newspaper/Magazine Article

Cardiovascular drugs: linked to many errors.

Santell JP. Drug Topics. June 20, 2005;149:HSE9.

This article summarizes analysis from MEDMARXSM data that revealed 80,000 errors involving cardiovascular drugs. The author makes recommendations for preventing such errors.

Journal Article > Study

Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients.

Chang CM, Liu PY, Yang YH, Yang YC, Wu CF, Lu FH. Pharmacotherapy. 2005;25:831-838.

The investigators surveyed 882 elderly outpatients in order to determine if the Beers criteria can predict adverse drug reactions (ADRs). They found a positive relationship between potentially inappropriate drug prescribing, as defined by the criteria, and ADRs.

Legislation/Regulation > Federal Legislation

21st Century Health Information Act of 2005.

HR 2234, 109th Cong, 1st Sess (2005).

This bill, which garnered bipartisan support, proposes developing health information technology networks (known as "Regional Health Information Organizations," or RHIOs) with a strong focus on state- and community-based efforts.  It is presently under consideration in the United States House of Representatives.

Journal Article > Study

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

Galanter WL, Didomenico RJ, Polikaitis A. J Am Med Inform Assoc. 2005;12:269-274.

This study evaluated the capacity of electronic alerts to reduce inappropriate prescribing of medications to inpatients with renal insufficiency. Investigators studied the likelihood of inappropriate prescribing 4 months before and 14 months after implementation of the automated alert system. Results indicated a nearly 50% decrease in administration of contraindicated medications and that receptivity to the alert system was greater in more experienced housestaff. The authors conclude that similar decision support systems can reliably improve care, but success of these systems requires provider compliance.

Journal Article > Study

Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.

Oyen LJ, Nishimura RA, Ou NN, Armon JJ, Zhou M. Am Heart Hosp J. 2005;3:75-81.

The investigators analyzed the efficacy of a computerized heparin nomogram system, which distributes interactive cues among the prescriber, nurse, pharmacist, and laboratory. They found significant improvements in the safety of this drug's administration.

Journal Article > Study

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

Mehta RH, Alexander JH, Van de Werf F, et al. JAMA. 2005;293:1746-1750.

This re-analysis of a previously conducted randomized controlled trial showed that patients who received an incorrect dose of a fibrinolytic agent (alteplase or tenecteplase) for treatment of ST-segment elevation myocardial infarction were more likely to experience adverse clinical outcomes. However, the analysis also showed the same increased risk for patients who received incorrect doses of the placebo versions of the study drugs. Many of the clinical factors that placed patients at risk for adverse outcomes also placed them at risk for dosing errors. This type of confounding is important to keep in mind when attributing adverse outcomes to antecedent errors in care.

Journal Article > Commentary

Five pitfalls in decisions about diagnosis and prescribing.

Klein JG. BMJ. 2005;330:781-783.

The author reviews five types of biased thinking that can negatively affect physicians' decision making and provides suggestions to overcome them.

Cases & Commentaries

The Forgotten Med

  • Web M&M

Russ Cucina, MD, MS; April 2005

Thinking that the patient's glycemic control had spontaneously improved (and not realizing that the patient was continuing to receive long-acting insulin injections), a physician discontinues daily glucose checks and insulin sliding scale orders. Four days later, the patient is found unresponsive and hypoglycemic.

Journal Article > Study

Implementing a commercial rule base as a medication order safety net.

Reichley RM, Seaton TL, Resetar E, et al. J Am Med Inform Assoc. 2005;12:383-389.

In this AHRQ-supported study, the investigators customized a commercial rule base to minimize nuisance alerts and improve alert specificity for overdosing.

Cases & Commentaries

A "Weak" Response

  • Web M&M

Anna B. Reisman, MD; December 2004

Feeling "weak" late at night, a patient calls his doctor's office. The covering physician misses a few clues, which might have prompted a different plan.

Cases & Commentaries

Discharge Fumbles

  • Spotlight Case
  • Web M&M

Alan Forster, MD, MSc; December 2004

A patient arrives at the ED in acute kidney failure; another patient arrives at the ED profoundly hypoglycemic. Both mishaps were determined to stem from medication errors at the time of discharge.

Cases & Commentaries

The Result Stopped Here

  • Web M&M

Michael Astion, MD, PhD; June 2004

Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.

Journal Article > Study

The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry.

Bobb A, Gleason K, Husch M, Feinglass J, Yarnold PR, Noskin GA. Arch Intern Med. 2004;164:785-792.

Cases & Commentaries

Intubation Mishap

  • Spotlight Case
  • Web M&M

Matthew B. Weinger, MD; George T. Blike, MD; September 2003

An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication.

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