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Search results for "United States of America"

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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.

Legislation/Regulation > Organizational Policy/Guidelines

ASHP IV Adult Continuous Infusions.

Bethesda, MD: American Society of Health-System Pharmacists; 2016.

Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards development project, this report describes how standardization can improve reliability and safety of intravenous therapy and provides guidance on safe concentrations for drugs.

Journal Article > Study

Standardization of compounded oral liquids for pediatric patients in Michigan.

Engels MJ, Ciarkowski SL, Rood J, et al. Am J Health Syst Pharm. 2016;73:981-990.

When pharmacists make up an individually prepared solution of liquid medication (a process known as compounding) for a pediatric patient, there is a risk for dosing error. This pre–post study demonstrated that implementing a standardized protocol for liquid medication compounding for children was well-received and widely adopted by pharmacists.

Journal Article > Study

Risk factors for i.v. compounding errors when using an automated workflow management system.

Deng Y, Lin AC, Hingl J, et al. Am J Health Syst Pharm. 2016;73:887-893.

Mistakes during preparation of intravenous (IV) medications can lead to dosing errors and adverse drug events. Analyzing data collected over 12 months in a hospital's automated IV compounding workflow management system, this study found that IV compounding errors occurred in less than 1% of cases and were usually intercepted through the automated system. These results suggest that existing processes do support safe medication use.

Journal Article > Study

Comparison of barcode scanning by pharmacy technicians and pharmacists' visual checks for final product verification.

Wang BN, Brummond P, Stevenson JG. Am J Health Syst Pharm. 2016;73:69-75.

In this study at a satellite pharmacy of a large academic hospital, barcode scanning by technicians was better at detecting dispensing errors than visual checking by pharmacists. This supports prior research showing that barcode scanning decreases dispensing errors and adverse drug events in the hospital.

Newspaper/Magazine Article

Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.

ISMP Safe Medicine. July/August 2015;13:1-3.

Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.

Press Release/Announcement

Move toward full use of metric dosing: eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. June 30, 2015.

Standard use of metric oral dosage instructions has been advocated as a medication safety strategy. Raising concerns around dosing cups that include drams and ounces as scales—measures no longer in clinical use—which are available from major vendors and may be found in health care facilities, this announcement recommends use of oral syringes that only measure in milliliters for oral liquid medications to prevent errors.

Journal Article > Study

Vaccination errors reported to the Vaccine Adverse Event Reporting System (VAERS), United States, 2000–2013.

Hibbs BF, Moro PL, Lewis P, Miller ER, Shimabukuro TT. Vaccine. 2015;33:3171-3178.

Vaccination-related errors reported to the National Vaccine Adverse Event Reporting System grew from 10 in the year 2000 to 4324 in 2013, potentially due to the introduction of new vaccines, increasingly complex vaccination schedules, and changes in reporting practices. The most common errors were dispensing vaccines at an inappropriate schedule or administering expired or incorrectly stored vaccines. One-fourth of reported errors caused an adverse health event, with 8% of these resulting in serious harm.

Newspaper/Magazine Article

Pharmacy dispensing errors: claims study emphasizes need for systematic vigilance.

Webb J. Drug Topics. March 10, 2015.

Pharmacies can serve as gatekeepers to ensure patients receive the correct medications. A 10-year study of claims data found that the majority of claims were related to wrong dose and wrong drug dispensing errors. This news article discusses injuries that resulted from the errors and provides recommendations to augment safety, including the design and use of order review and quality control systems to reduce the risk of human error in pharmacy services.

Journal Article > Study

Color-coded prefilled medication syringes decrease time to delivery and dosing error in simulated emergency department pediatric resuscitations.

Moreira ME, Hernandez C, Stevens AD, et al. Ann Emerg Med. 2015;66:97-106.

Medication errors are common during pediatric resuscitation situations. This study found that use of prefilled and color-coded syringes reduced time needed to prepare and administer medications and significantly decreased dosing errors during simulated resuscitations.

Audiovisual

Report suggests trend in prescription drug errors filled by pharmacists.

McKinnon C. WBZ-TV. February 13, 2015.

Spotlighting how pharmacies have reported 194 serious medication errors to the Massachusetts State Department of Public Health since 2010, this news video raises concerns about production pressures and other process issues that may have contributed to the mistakes.

Journal Article > Study

The effect of a safe zone on nurse interruptions, distractions, and medication administration errors.

Yoder M, Schadewald D, Dietrich K. J Infus Nurs. 2015;38:140-151.

Implementation of a safe zone—which included marked quiet areas for medication preparation, adhering to a checklist for medication processes, and educating staff about distractions—to minimize interruptions during medication administration did not improve medication error rates, but was associated with an increase in patient satisfaction.

Newspaper/Magazine Article

FDA begins inquiry after death and illness from saline bags meant for training.

Tavernise S. New York Times. January 15, 2015.

This newspaper article discusses an investigation into how a saline solution that had been manufactured specifically for training purposes was inadvertently distributed and used for actual care and led to patient harm and death.

Audiovisual

Family matters: pharmacy mix-ups.

Suares W. FOX 25 KOKH-TV. July 30, 2014.

This video news segment reports how incorrect medications can be dispensed from pharmacies, notes a lack of regulation mandating that pharmacy errors are reported, and offers tips for patients to reduce risks.

Newspaper/Magazine Article

With oral chemotherapy, we simply must do better!

ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4.

To illustrate hazards associated with dispensing more than one dose of certain medications, this newsletter article describes an incident involving an accidental overdose of self-administered oral chemotherapy which resulted in a patient's death. Recommendations to reduce the potential for errors include ensuring labels conform to FDA labeling practices, dispensing only single doses, and providing medication counseling and written instructions for patients.

Journal Article > Study

Nursing perception of the impact of automated dispensing cabinets on patient safety and ergonomics in a teaching health care center.

Rochais E, Atkinson S, Guilbeault M, Bussières JF. J Pharm Pract. 2014;27:150-157.

Nurses felt that the introduction of automated dispensing cabinets improved medication safety and made their work easier.

Journal Article > Study

Pharmacy dispensing of electronically discontinued medications.

Allen AS, Sequist TD. Ann Intern Med. 2012;157:700-705.

Electronic prescribing systems have been shown to prevent medication errors in the outpatient setting. However, such systems do not routinely notify pharmacies if a clinician has decided to stop prescribing a medication, creating the potential for harm. Conducted in 15 primary care practices that use a commercial electronic medical record system, this study found that 1.5% of prescriptions discontinued by physicians were subsequently dispensed at least once by pharmacies. Since these medications included high-risk therapies such as antidiabetic and antiplatelet agents, some patients may have experienced preventable harm as a result. This study identifies a previously undocumented type of error in ambulatory care and describes the need to harness technology to facilitate bidirectional communication between providers.

Newspaper/Magazine Article

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

ISMP Medication Safety Alert! Acute Care Edition. September 6, 2012;17:1-4.

This newsletter article discusses results from a survey of community pharmacists on how time guarantees affect their practice.

Journal Article > Study

Effect of social influences on pharmacists' intention to report adverse drug events.

Gavaza P, Brown CM, Lawson KA, Rascati KL, Steinhardt M, Wilson JP. J Am Pharm Assoc. 2012;52:622-629.

This survey explored factors that influence pharmacist reporting of medication errors and found that regulatory requirements and peer influence both made reporting more likely.

Newspaper/Magazine Article

Events associated with the prescribing, dispensing, and administering of medication loading doses.

Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.

This article discusses data on loading dose errors and provides strategies to reduce risks of such adverse drug events.

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