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Search results for "Ordering/Prescribing Errors"

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Journal Article > Study

Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.

Quist AJL, Hickman TT, Amato MG, et al. Am J Health Syst Pharm. 2017;74:499-509.

Evidence suggests that computerized provider order entry (CPOE) systems improve medication safety by mitigating prescribing errors. However, CPOE systems may contribute to errors when user-centered design is not taken into account. In this study, researchers standardized the assessment of 10 distinct inpatient and ambulatory CPOE systems across 6 health care institutions to determine how variation in drug name display may increase the risk of medication errors. Using test patient scenarios, they found significant variation in drug name display, including inconsistencies with regard to the display of brand and generic names. Providers could theoretically prescribe both the brand and generic drug, increasing the risk for patient harm. A recent Annual Perspective discussed the benefits and limitations of CPOE with regard to patient safety.

Journal Article > Commentary

Elimination of emergency department medication errors due to estimated weights.

Greenwalt M, Griffen D, Wilkerson J. BMJ Qual Improv Rep. 2017;6:u214416.w5476.

Inaccurate assessments of patient weight can lead to medication dosing errors. This commentary describes how a single-center quality improvement project drew from errors in the emergency department associated with incorrect patient weight estimates and applied storytelling, Lean Six Sigma, and Fishbone diagram approaches to develop and test a method of entering weights that eliminated these errors during the 6-month intervention period.

Journal Article > Government Resource

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

  • Classic

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 > Study

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis.

Sun EC, Dixit A, Humphreys K, Darnall BD, Baker LC, Mackey S. BMJ. 2017;356:j760.

Concurrent use of opioids and benzodiazepines increases risk for adverse drug events. This retrospective analysis of medical claims found that the risk of emergency department visit was greater for patients with concurrent use of these two medication classes compared to patients on opioids alone. This finding supports the recommendation to avoid coprescribing these two medication classes.

Journal Article > Study

'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective.

Ferguson J, Keyworth C, Tully MP. Res Social Adm Pharm. 2017 Mar 2; [Epub ahead of print].

This qualitative study of physician trainees found that they welcomed feedback about prescribing errors. Feedback was perceived to be most useful if it was timely, specific, and included group discussion. Participants found email feedback to be less useful. These data should inform future efforts to provide prescribing feedback.

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.

Journal Article > Study

Ordering interruptions in a tertiary care center: a prospective observational study.

Dadlez NM, Azzarone G, Sinnett MJ, et al. Hosp Pediatr. 2017;7:134-139.

Interruptions are known to contribute to medication errors. This direct observation study found that resident physicians and physician assistants experienced 57 interruptions per 100 medication orders. The authors suggest that inpatient health systems should implement strategies to reduce interruptions during medication ordering.

Journal Article > Study

E-prescribing and adverse drug events: an observational study of the Medicare Part D population with diabetes.

Gabriel MH, Powers C, Encinosa W, Bynum JP. Med Care. 2017;55:456-462.

Hypoglycemia is a common and severe adverse drug event among patients with diabetes. This retrospective study of claims data found that Medicare patients with diabetes were less likely to be hospitalized or seen in the emergency department for hypoglycemia if their medications were prescribed electronically, compared to those receiving fewer or no electronic prescriptions. These findings add to the literature demonstrating the benefits of electronic prescribing.

Cases & Commentaries

Hazards of Loading Doses

  • Web M&M

Jeffrey J. Mucksavage, PharmD, and Eljim P. Tesoro, PharmD; January 2017

An emergency department physician ordered a loading dose of IV phenytoin for a woman with a history of seizures and cardiac arrest. However, he failed to order that the loading dose be switched back to an appropriate (and lower) maintenance dose, and 3 days later the patient developed somnolence, severe ataxia, and dysarthria. Her serum phenytoin level was 3 times the maximum therapeutic level.

Journal Article > Review

The effect of prescriber education on medication-related patient harm in the hospital: a systematic review.

Bos JM, van den Bemt PMLA, de Smet PAGM, Kramers C. Br J Clin Pharmacol. 2017;83:953-961.

Medication safety remains a critical patient safety priority. This systematic review found that educating prescribers about medication errors in hospitals has not been demonstrated to reduce adverse drug events. The authors suggest that further work is needed to develop and evaluate prescriber education programs.

Journal Article > Study

Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria.

Frankenthal D, Israeli A, Caraco Y, et al. J Am Geriatr Soc. 2017;65:e33-e38.

Inappropriate medication prescribing to older patients increases the risk of adverse drug events. This retrospective study assessed the sustainability of orally communicated medication recommendations based on the STOPP (Screening Tool of Older Persons potentially inappropriate Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment) criteria as compared to written medication review over time. The prevalence of potentially inappropriate prescriptions remained lower in the group receiving the orally communicated recommendations at 24-month follow-up. The authors conclude that direct communication about medications between pharmacists and prescribing providers may be more effective than written medication review.

Newspaper/Magazine Article

Is an indication-based prescribing system in our future?

ISMP Medication Safety Alert! Acute Care Edition. November 17, 2016;21:1-5.

Health information technology has enhanced prescribers' ability to document the purpose of medications they order. This newsletter article reviews weaknesses in electronic prescribing systems and recommends incorporating indication-based prescribing as the "sixth right" of safe medication use. The piece highlights how making indication information available can help inform medication communication, selection, adherence, and reconciliation.

Journal Article > Study

Mandatory provider review and pain clinic laws reduce the amounts of opioids prescribed and overdose death rates.

Dowell D, Zhang K, Noonan RK, Hockenberry JM. Health Aff (Millwood). 2016;35:1876-1883.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

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.

Journal Article > Study

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

Barry E, O'Brien K, Moriarty F, et al; PIPc Project Steering group. BMJ Open. 2016;6:e012079.

Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.

Book/Report

Report on the Safe Use of Pick Lists in Ambulatory Care Settings.

Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.

Standard term selection tools—like pick lists or drop-down menus—in information technology can create opportunities for user error due to human factors. This publication explores how mistakes such as selecting the wrong drug from an ordering pick list can occur in the ambulatory environment. The report includes recommendations and resources to help enhance medication safety when using these tools.

Journal Article > Review

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

Brown CL, Mulcaster HL, Triffitt KL, et al. J Am Med Inform Assoc. 2017;24:432-440.

The use of computerized provider order entry (CPOE) systems, in which clinicians place orders for tests, labs, and medications electronically, has grown rapidly in both inpatient and outpatient settings. Although research has shown that implementation of CPOE can reduce prescribing errors in both inpatient and outpatient settings, additional studies have found that errors continue to occur. In this systematic review, researchers identified multiple factors linked to CPOE prescribing errors, including flaws in functional design and underlying clinical decision support systems, as well as insufficient system flexibility leading to user workarounds. The authors suggest that further consideration must be given to human factors design principles. A recent Annual Perspective highlighted some of the ongoing challenges associated with CPOE.

Journal Article > Review

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Brown CL, Reygate K, Slee A, et al. Int J Pharm Pract. 2017;25:195-202.

Insufficient training on electronic health record systems can hinder user satisfaction. This literature review assessed the evidence on training methods, such as simulation scenarios and classroom-based sessions, for electronic prescribing systems. The authors suggest that future research should examine how to educate users about challenges associated with electronic systems.

Journal Article > Commentary

Incorporating indications into medication ordering—time to enter the age of reason.

Schiff GD, Seoane-Vazquez E, Wright A. N Engl J Med. 2016;375:306-309.

Clear communication during medication prescribing can enhance safety. This commentary advocates for indications-based prescribing coupled with health information technology as a way to improve team communication, medication reconciliation, and patient education and compliance.

Journal Article > Review

Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review.

Morin L, Laroche ML, Texier G, Johnell K. J Am Med Dir Assoc. 2016;17:862.e1-e9.

Adverse drug events in older patients are common, and those living in nursing homes may be at particularly high risk for receiving inappropriate medications. This systematic review found that almost half of nursing home residents are exposed to potentially inappropriate medications and that prevalence has increased over time.

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