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Search results for "Ordering/Prescribing Errors"

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  • Ordering/Prescribing Errors
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Press Release/Announcement

FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 4, 2016.

This announcement alerts prescribers to differences in two oral formulations of the same medication that can lead to dosing errors. The FDA suggests that clinicians specify dosage form, strength, and frequency on prescriptions for this drug to reduce the risk of patient harm and recommend that pharmacists follow up with prescribers if such information is missing.

Journal Article > Study

Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study.

  • Classic

Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Ann Intern Med. 2016;164:1-9.

Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This cohort study examined treatment patterns for patients who had experienced a nonfatal opioid overdose. More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17% of those patients experienced another overdose event. An accompanying editorial notes the lack of systems to ensure clinicians' awareness of patients' opioid overdoses and recommends enhancing training and support so that clinicians are prepared to treat chronic pain and addiction. New approaches are urgently needed given this crisis in medication safety. A previous WebM&M commentary discussed the challenges of prescribing safely for chronic opioid users.

Book/Report

Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.

Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.

Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.

Journal Article > Study

The vulnerabilities of computerized physician order entry systems: a qualitative study.

  • Classic

Slight SP, Eguale T, Amato MG, et al. J Am Med Inform Assoc. 2016;23:311-316.

Electronic health record implementation has improved safety through mechanisms such as computerized provider order entry (CPOE), but it has also had unintended adverse effects on patient safety. Reviewing incident reports from the US Pharmacopeia where CPOE was a contributing factor, this study sought to determine whether current CPOE systems are vulnerable to similar errors. Investigators then entered potentially problematic medication orders in various CPOE systems using a simulated approach. They encountered multiple usability hurdles including confusion with critical and irrelevant alerts, workflow issues, and variability in how orders were entered. These results demonstrate the need for robust independent usability testing of CPOE within electronic health records to support patient safety.

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.

  • Classic

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

Examining variations in prescribing safety in UK general practice: cross sectional study using the Clinical Practice Research Datalink.

Stocks SJ, Kontopantelis E, Akbarov A, Rodgers S, Avery AJ, Ashcroft DM. BMJ. 2015;351:h5501.

Prescribing errors are a serious source of patient harm in primary care. This cross-sectional study in the United Kingdom found wide variation in the prevalence of potentially hazardous prescribing ranging from nearly zero to 10%, and for inadequate medication monitoring ranging from 10% to 42% between practices.

Journal Article > Study

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

Keers RN, Williams SD, Vattakatuchery JJ, et al. J Clin Pharm Ther. 2015;40:645-654.

In this study, prospective pharmacist review of written prescriptions for adults discharged from mental health hospitals found that about 20% contained medication errors. These findings underscore the risks of adverse events in the postdischarge period and the need for more oversight of discharge prescriptions.

Journal Article > Commentary

Computerised prescribing for safer medication ordering: still a work in progress.

Schiff GD, Hickman TT, Volk LA, Bates DW, Wright A. BMJ Qual Saf. 2016;25:315-319.

The unintended consequences related to implementation of health information technologies have been widely documented. In this commentary, the authors offer insights regarding a government-funded investigation of 10 computerized provider order entry systems, discuss weaknesses in these systems, and make recommendations to focus on designing around human factors, enhancing workflow, and improving reporting.

Audiovisual

Seven (potentially) deadly prescribing errors.

Graham LR, Scudder L, Stokowski L. Medscape Multispecialty. October 22, 2015.

Errors in the prescribing process can lead to adverse drug events. This slide set provides information about common problems in prescribing such as selecting the wrong drug in a drop-down menu, formulation mix-ups, alert fatigue, poor quality of data in health information systems, and use of ambiguous abbreviations.

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 > Commentary

Hospice diagnosis: polypharmacy—a teachable moment.

Larson CK, Kao H. JAMA Intern Med. 2015;175:1750-1751.

Overprescribing can increase risk of dementia, particularly among older patients. This commentary describes an incident involving a patient with moderate dementia that worsened when opioids were prescribed following a fall. After a geriatrician evaluated the patient and suspected polypharmacy, the drugs were stopped, caregivers were educated about how to treat the patient, and the patient improved. Highlighting the importance of environmental interventions in treating this patient, the author reviews strategies to address neuropsychiatric symptoms of dementia.

Newspaper/Magazine Article

FDA Advise-ERR: avoid using the error-prone abbreviation, TPA.

ISMP Medication Safety Alert! Acute Care Edition. September 24, 2015;20:1,4-5.

Describing incidents involving abbreviation confusion for ACTIVASE (alteplase) and TNKASE (tenecteplase) that resulted in wrong-drug errors, this newsletter article recommends ways to prevent such errors, including avoiding use of abbreviations and removing certain abbreviations from standardized order sets.

Journal Article > Study

Pediatric prehospital medication dosing errors: a mixed-methods study.

Hoyle JD Jr, Sleight D, Henry R, Chassee T, Fales B, Mavis B. Prehosp Emerg Care. 2016;20:117-124.

Medication errors are common in pediatric patients who require care from emergency medical services. This study found that most paramedics had limited experience and comfort in administering medications to children. Investigators identified several remediable barriers to improving medication safety in this setting.

Journal Article > Study

Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system.

Dekarske BM, Zimmerman CR, Chang R, Grant PJ, Chaffee BW. Int J Med Inform. 2015;84:1085-1093.

Alert fatigue is the Achilles heel of medication ordering with computerized physician order entry. This randomized controlled trial found that the appropriateness of alert overrides increased with implementation of a customized list of alert override reasons, compared with default options, in a CPOE system. This demonstrates the need to develop more clinically relevant reasons for overriding alerts in order to enhance the safety of medication prescribing.

Journal Article > Study

Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews.

Lloyd M, Watmough SD, O'Brien SV, Furlong N, Hardy K. Res Social Adm Pharm. 2016;12:461-474.

According to these focus groups, pharmacists recognized the importance of providing timely feedback to physicians regarding prescription errors, but they also described barriers to feedback such as time pressures and concerns about negative effects on interpersonal rapport.

Journal Article > Study

Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center.

Gorbach C, Blanton L, Lukawski BA, Varkey AC, Pitman EP, Garey KW. Am J Health Syst Pharm. 2015;72:1471-1474.

A key patient safety role of pharmacists involves verifying orders placed by clinicians for accuracy and completeness. This retrospective study from an academic medical center found that pharmacists were more likely to commit errors in the verification process when they had to review more than 400 orders in one 8-hour shift or if they were working the evening shift (compared to the day or night shift).

Journal Article > Study

Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.

MacKay M, Anderson C, Boehme S, Cash J, Zobell J. Nutr Clin Pract. 2016;31:195-206.

Computerized provider order entry with clinical decision support can be a powerful tool for alerting clinicians to potential prescribing errors. In this study at a large pediatric institution, implementation of a computerized provider order entry program for total parenteral nutrition resulted in a reduction in prescribing errors.

Journal Article > Study

Incidence- versus prevalence-based measures of inappropriate prescribing in the Veterans Health Administration.

Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. J Am Geriatr Soc. 2015;63:1601-1607.

This health system performance study ranked sites within the Veterans Affairs health system using two measures of potentially inappropriate prescribing in older veterans. Researchers found that sites ranked similarly when they used new potentially inappropriate medications to measure performance compared to when they used existing potentially inappropriate medications as the measure. These results suggest that measuring new potentially inappropriate prescriptions is a feasible strategy worthy of further study.

Cases & Commentaries

Baffled by Botulinum Toxin

  • Web M&M

Krishnan Padmakumari Sivaraman Nair, DM; July/August 2015

A 5-year-old boy with transverse myelitis presented to the rehabilitation medicine clinic for scheduled quarterly botulinum toxin injections to his legs for spasticity. Halfway through the course of injections, the patient's mother noted her son was tolerating the procedure "much better than 3 weeks earlier"—the patient had been getting extra injections without the physicians' knowledge. Physicians discussed the risks of too-frequent injections with the family. Fortunately, the patient had no adverse effects from the additional injections.

Journal Article > Study

Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients: prospective study in 20 UK hospitals.

Ashcroft DM, Lewis PJ, Tully MP, et al. Drug Saf. 2015;38:833-843.

Medication prescribing errors are common in hospitals, and previous research has suggested junior doctors may make the most mistakes. In this prospective study, pharmacists in 20 hospitals in the United Kingdom reviewed medication orders and prescribing errors. More than 120,000 orders were reviewed over the 7-day study period, and prescribing errors were found in 8.8% of medication orders. Doctors in their first 2 years of training were more than twice as likely to make prescribing errors compared to doctors that had completed training. However, many of these errors were minor and the rates of serious or potentially fatal errors did not differ between trainees and senior physicians, suggesting that interventions should focus on all physicians. A 2014 AHRQ PSNet Annual Perspective reviewed current trends to address patient safety in medical education.

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