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Approach to Improving Safety
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Search results for "United States of America"

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Journal Article > Study

Drug-related harms in hospitalized Medicare beneficiaries: results from the Healthcare Cost and Utilization Project, 2000–2008.

Shamliyan TA, Kane RL. J Patient Saf. 2016;12:89-107.

Prior studies have shown that older patients are particularly vulnerable to medication errors. This cohort study documents a marked increase in both hospitalizations due to adverse drug events and in Medicare patients between 2000 and 2008. During that time frame, the incidence of in-hospital adverse drug events and the severity of harm experienced by patients rose as well.

Journal Article > Study

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement.

  • Classic

Slight SP, Beeler PE, Seger DL, et al. BMJ Qual Saf. BMJ Qual Saf 2017;26:217-225.

Clinical decision support systems are intended to improve safety by providing clinicians with information about potential harms—principally harmful drug interactions and allergies—at the point of care. Analyzing more than 150,000 drug allergy warnings in the inpatient and outpatient settings within a single health care system, this study examined how often the warnings were overridden and the appropriateness of prescribers' reasons for doing so. Clinicians overrode 81% of warnings in hospitalized patients and 77% of alerts in outpatients. More than 96% of the overrides were judged appropriate by independent clinical reviewers. These proportions are similar to prior studies. A common appropriate reason for overriding was that the patient had actually tolerated the drug in question, leading the authors to call for improving the accuracy of allergy documentation in electronic medical records. A few classes of drugs accounted for a large proportion of overridden alerts, suggesting that enhancing the accuracy of allergy warnings for these drugs could significantly reduce the overall burden of alerts. Given that alert fatigue is an increasingly recognized patient safety hazard, creating tailored alerts could help clinical decision support systems achieve their potential to improve safety.

Journal Article > Study

Patient, physician, medical assistant, and office visit factors associated with medication list agreement.

Reedy AB, Yeh JY, Nowacki AS, Hickner J. J Patient Saf. 2016;12:18-24.

Medication reconciliation is critical to avoiding adverse drug events. This direct observation study examined primary care interactions between patients, medical assistants, and physicians. The study aimed to characterize factors associated with medication agreement between the electronic health record and patient reports at the end of the visit. Less than half of patients reached medication agreement, consistent with prior studies. Investigators assessed multiple techniques to reach medication agreement, including looking at bottles, asking about each medication, and providing paper copy of the medication list. However, only one technique was significantly associated with medication agreement: the medical assistant asking an open-ended question to initiate medication review. This study did not examine patient engagement, which enhanced medication reconciliation in a previous study.

Audiovisual > Image/Poster

ADVERSE drug events: incidence and risk reduction across the care continuum.

Wanderer JP, Rathmell JP. Anesthesiology. 2016;124:A23.

This infographic provides information about adverse drug events, including how frequently and where they occur and strategies to reduce risk of such errors (e.g., computerized provider order entry and barcode medication administration).

Tools/Toolkit

Contemporary View of Medication-Related Harm. A New Paradigm.

Rockville, MD: National Coordinating Council for Medication Error Reporting and Prevention; 2015.

Medication errors are a common factor in health care–associated harm. Lack of clarity on types of medication-related incidents has the potential to create confusion and hinder improvement efforts. This tool provides a decision tree to distinguish whether an incident is an adverse drug reaction, adverse drug event, or medication error and determine if it was preventable.

Newspaper/Magazine Article

Analysis of ISMP National Vaccine Errors Reporting Program—Part 1 and Part 2.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2014;19:1-6. March 26, 2015;20:1-4.

This newsletter series reports on 2 years of data collected during a national effort to collect vaccine administration errors. The first article summarizes information about the types of vaccine errors reported and why they occur. The second article discusses risks during vaccine use and offers recommendations to prevent them.

Tools/Toolkit > Database/Directory

MEDMARX®.

Rockville, MD: U.S. Pharmacopeia; 2011.

This commercial database tracks both adverse drug reactions and medication errors submitted by participating hospitals. Subscribers have access to national data, which can be used for trend analysis and internal benchmarking.

Journal Article > Study

Analysis of risk factors for adverse drug events in critically ill patients.

Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Crit Care Med. 2012;40:823-828.

This cohort study identified patient- and drug-specific factors that increased the risk of adverse drug events in intensive care unit patients.

Journal Article > Commentary

To tell the truth, the whole truth, may do patients harm: the problem of the nocebo effect for informed consent.

Wells RE, Kaptchuk TJ. Am J Bioeth. 2012;12:22-29.

This commentary explores how awareness of potential adverse effects can result in patient anxiety, distress, and extra treatment.

Journal Article > Study

Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia.

Lau DT, Mercaldo ND, Shega JW, Rademaker A, Weintraub S. Am J Alzheimers Dis Other Demen. 2011;26:606-615.

Elderly patients with dementia who were prescribed more than five medications were at greater risk of long-term functional decline. However, prescribing potentially inappropriate medications (as determined by the Beers criteria) was not correlated with worsened functional status. Other studies have also called the utility of Beers criteria into question.

Newspaper/Magazine Article

Conservative prescribing needed to improve medication safety.

ISMP Medication Safety Alert! Acute Care Edition. November 17, 2011;16:1-3.

This piece highlights conservative prescribing as a strategy to prevent overuse of medication.

Journal Article > Study

Improving patient safety via automated laboratory-based adverse event grading.

Niland JC, Stiller T, Neat J, Londrc A, Johnson D, Pannoni S. J Am Med Inform Assoc. 2012;19:111-115.

This study reports on the development of an automated system for identifying adverse events in clinical trial participants. The system was both more accurate and more efficient than traditional manual record review.

Journal Article > Study

Potential safety gaps in order entry and automated drug alerts: a nationwide survey of VA physician self-reported practices with computerized order entry.

Spina JR, Glassman PA, Simon B, et al. Med Care. 2011;49:904-910.

In contrast to most hospitals and clinics, the Veterans Affairs (VA) health care system has had a fully electronic health record with computerized provider order entry for several years. In this survey, VA physicians generally had positive impressions of the system, with nearly 90% feeling the system improved drug safety and nearly half reporting that serious drug interaction warnings were "very useful." However, the accuracy of drug–drug interaction and allergy warnings within this system are partially dependent upon clinicians manually entering medications prescribed by non-VA providers. As more than one quarter of respondents admitted to not always entering this data, this study highlights the importance of medication reconciliation in establishing accurate medication lists in the ambulatory care setting.

Newspaper/Magazine Article

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

Detailing a case in which latent failures led to patient harm, this article encourages health care providers investigating adverse events to consider how both active and latent failures may line up to cause errors.

Journal Article > Study

Medication assessments by care managers reveal potential safety issues in homebound older adults.

Golden AG, Qiu D, Roos BA. Ann Pharmacother. 2011;45:492-498.

This study found that most homebound older adults were taking over-the-counter medications (75%), dietary supplements (42%), and using potentially inappropriate medications (25%). As most of these medications are not covered by Medicare, other strategies may be needed to ensure safe prescribing and careful monitoring.

Journal Article > Study

Evaluation of the role of the critical care pharmacist in identifying and avoiding or minimizing significant drug–drug interactions in medical intensive care patients.

Rivkin A, Yin H. J Crit Care. 2011;26:104.e1-104.e6.

This study found that having a clinical pharmacist participate in daily rounds reduced the number of clinically important drug–drug interactions (DDIs) after therapy modification. Lower numbers of DDIs were also associated with shorter lengths of stay, suggesting a potential business case for greater pharmacist involvement in this patient population.

Press Release/Announcement

Benzocaine sprays marketed under different names, including Hurricaine, Topex, and Cetacaine.

FDA Public Health Advisory [US Food and Drug Administration Web site]. January 19, 2010.

This FDA announcement alerts clinicians to reports of adverse events associated with benzocaine sprays and includes considerations for safer use of the sprays.

Journal Article > Commentary

Poor medication history plus slow symptom onset delays a diagnosis.

Wilkin T, Hale LS, Claiborne RA. JAAPA. October 2009;22:39-41.

This case report presents complete documentation of home medications as a strategy to prevent delay in diagnosis due to unrecognized medication adverse effects.

Newspaper/Magazine Article

Medication mistakes that can kill.

Haiken M. Caring.com. August 17, 2009.

To help consumers use medications safely, this article describes 10 common medication mistakes and provides tips on how effective communication and clarification can prevent them.

Book/Report

2009 Older Adults' Knowledge About Medications That Can Impact Driving.

MacLennan PA, Owsley C, Rue LW III, McGwin G Jr. Washington, DC: American Automobile Association Foundation for Traffic Safety; August 2009.

This report provides results of a survey about older adults' awareness of common medications that may impair the ability to drive.

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