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Search results for "United States of America"

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Newspaper/Magazine Article

Death due to pharmacy compounding error reinforces need for safety focus.

ISMP Medication Safety Alert! Acute Care Edition. June 15, 2017;22:1-4.

Compounding pharmacies prepare medicines for patients that aren't available as commercial products. Reviewing a case involving a pediatric patient who died after receiving a compounded oral liquid suspension that contained the wrong medication, this newsletter article discusses weaknesses in compounding processes that contributed to the incident. Recommendations for pharmacies to reduce opportunities for error include independent double-checks and designated areas for compounding activities.

Audiovisual > Audiovisual Presentation

Medication Safety Certificate Program.

American Society of Health-System Pharmacists and Institute for Safe Medication Practices.

Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.

Book/Report

Communicating Clearly About Medicines: Proceedings of a Workshop—in Brief.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2017.

Medication safety is a global health care concern. This workshop proceedings report highlights expert opinion on how to improve the clarity of medication information and the way it is communicated to patients. Panelists focused on elements of the process such as the patient experience, health literacy, medication instructions, and design of medication packaging.

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Journal Article > Study

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.

Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.

Special or Theme Issue

Polypharmacy.

Zagaria MAE, ed. Clin Geriatr Med. 2017;33:153-292.

Older patients are likely to be prescribed multiple medications, which can increase risks. Articles in this special issue explore polypharmacy in a variety of care settings and provide tactics for improvement, such as enhancing care integration for older patients through medication reconciliation and deprescribing initiatives.

Web Resource > Multi-use Website

Medication Without Harm: WHO's Third Global Patient Safety Challenge.

Geneva, Switzerland: World Health Association.

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients. This website provides information about a worldwide effort to improve medication safety by examining elements of medication prescription, distribution, and use that are vulnerable. The campaign will highlight best practices to address these weaknesses.

Journal Article > Commentary

Polypharmacy in the elderly—when good drugs lead to bad outcomes: a teachable moment.

Carroll C, Hassanin A. JAMA Intern Med. 2017 Apr 24; [Epub ahead of print].

Geriatric patients are particularly vulnerable to adverse drug events due to comorbidities, complicated care plans, and polypharmacy. This commentary describes how using STOPP criteria and performing indication mapping can help reduce polypharmacy and improve patient safety.

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

Standardizing concentrations of adult drug infusions in Indiana.

Walroth TA, Dossett HA, Doolin M, et al. Am J Health Syst Pharm. 2017;74:491-497.

Standardizing drug concentrations addresses a medication safety concern for both adult and pediatric inpatients. This commentary describes a state-wide consensus project that reconciled existing lists of adult IV drug concentrations to develop a final list of 26 IV concentrations to reduce risks of medication errors.

Journal Article > Study

Measuring to improve medication reconciliation in a large subspecialty outpatient practice.

Kern E, Dingae MB, Langmack EL, Juarez C, Cott G, Meadows SK. Jt Comm J Qual Patient Saf. 2017;43:212-223.

Achieving accurate medication reconciliation during care transitions helps promote patient safety. Using data from the electronic health record, researchers developed and validated metrics to assess performance of medication reconciliation in the ambulatory setting.

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 > Study

30-day potentially avoidable readmissions due to adverse drug events.

Dalleur O, Beeler PE, Schnipper JL, Donzé J. J Patient Saf. 2017 Mar 17; [Epub ahead of print].

Adverse drug events after hospital discharge can lead to preventable readmissions. In this retrospective observational study, physicians reviewed medical records to determine underlying reasons for adverse drug events in readmitted patients. Nearly half of the adverse drug events were due to inappropriate prescribing, and the remainder were due to inadequate patient education or self-monitoring. These results underscore the importance of medication communication in enhancing safety.

Journal Article > Government Resource

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

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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.

Newspaper/Magazine Article

Medication errors attributed to health information technology.

Lawes S, Grissinger M. PA-PSRS Patient Saf Advis. March 2017;14:1-8.

The unintended consequences associated with health information technologies for medication management are well documented. Drawing from 889 medication error reports submitted over a 6-month period, this analysis found that more than half of the recorded incidents were associated with computerized provider order entry. Staff reporting of medication errors and near misses is key to identifying trends and consequently developing system improvements to reduce risks of such incidents.

Journal Article > Study

Pediatric prehospital medication dosing errors: a national survey of paramedics.

Hoyle JD Jr, Crowe RP, Bentley MA, Beltran G, Fales W. Prehosp Emerg Care. 2017;21:185-191.

This survey of paramedics found that pediatric dosing errors in the prehospital period are common. Respondents used varied methods for estimating weight of pediatric patients in order to calculate drug doses, and they advocated for pediatric training and standardized weight estimation methods to reduce risks. These findings suggest several possible interventions to enhance pediatric medication safety in the prehospital setting.

Journal Article > Study

Burden of hospitalizations related to adverse drug events in the USA: a retrospective analysis from large inpatient database.

Poudel DR, Acharya P, Ghimire S, Dhital R, Bharati R. Pharmacoepidemiol Drug Saf. 2017;26:635-641.

Analyzing data from the AHRQ Healthcare Cost and Utilization Project, this study found that hospitalizations related to adverse drug events increased from 2008 to 2011. These hospitalizations are common and costly, and they demonstrate higher odds of in-hospital death. These data underscore the urgent need to enhance medication safety.

Journal Article > Review

The effects of bar-coding technology on medication errors: a systematic literature review.

Hutton K, Ding Q, Wellman G. J Patient Saf. 2017 Feb 24; [Epub ahead of print].

This systematic review of barcoding medication administration demonstrates consistent reductions in medication errors across all included studies following the introduction of barcoding. The authors advocate for continued uptake of this health information technology strategy to enhance safety.

Journal Article > Study

Meaningful use of health information technology and declines in in-hospital adverse drug events.

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Furukawa MF, Spector WD, Limcangco MR, Encinosa WE. J Am Med Inform Assoc. 2017 Feb 16; [Epub ahead of print].

Electronic health records have both safety benefits and unintended consequences. This analysis used data from the 2010–2013 Medicare Patient Safety Monitoring System to compare the incidence of in-hospital adverse events among hospitals that did and did not meet meaningful use requirements for health information technology (IT), according to the Healthcare Information Management Systems Society Analytics Database. Investigators found that hospitals that met meaningful use criteria also reported fewer adverse events. Although the study design does not establish a causal relationship between implementation of health IT and the decline in adverse events, the authors argue that these advances in health IT contributed to this patient safety improvement.

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