Search results for "United States of America"

Anticoagulation medications are often associated with adverse drug events. This study found that less-than-daily monitoring of anticoagulation in hospitalized patients is associated with more frequent out-of-range values, suggesting that daily monitoring is safer.

Simulation training has been increasingly adopted as a valuable teaching tool, particularly for surgeons and anesthesiologists. This study found that allowing first-year anesthesia residents to independently fail at a scenario, causing simulated morbidity or mortality, resulted in better performance on a different, but similar, scenario 6 months later.

Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.

This announcement reports on potential for falsely elevated glucose readings in patients taking parenteral maltose, parenteral galactose, or oral xylose and provides a list of products that may interfere with glucose monitoring.

This article addresses a drug–device interaction in which patients receiving a certain peritoneal dialysis solution may have falsely elevated blood glucose levels when measured with point-of-care blood glucose monitors.

Electronic reminders to clinicians are one of the earliest methods used to improve patient safety. In this cluster-randomized controlled trial conducted in primary care clinics, clinicians received targeted reminders within the existing electronic medical record prompting them to order laboratory tests to detect adverse medication effects. The most encouraging study result was that clinicians were generally already monitoring patients as recommended—in contrast to data from prior studies—and as a result, the reminders did not appreciably increase test ordering. Prior research has addressed barriers to effective implementation of electronic reminders.

This randomized study found that academic detailing yielded modest impact on appropriate monitoring of patients started on selected high-risk medications. A past study also demonstrated limited success with academic detailing as a sole intervention to promote medication safety.

Increased use of computerized physician order entry (CPOE) systems has focused greater attention on integrating effective clinical decision support systems (CDSS) to modify prescribing behavior and reduce errors. This study randomized primary care physicians to receive specific laboratory monitoring alerts for a selected group of medications and compared their practices to a control group that received no CDSS. Investigators found no difference between the two physician groups. They discuss the tension between having too many reminders and effectively delivering important reminders. These findings mirror those of a past review that suggested the impact of CDSS on patient outcomes compared to the impact on care without CDSS remains unclear, with a need for better evaluative strategies.

This medication safety study describes a process to prevent unsafe medication dispensing from automated systems. Investigators evaluated the types and frequencies of medications administered by override, used an expert panel to revise the medication override list, developed a tool for override monitoring, and specifically measured the change in override use of opioids (a high-alert medication class). The authors discuss their multifaceted approach, present examples of the changes that resulted, and offer steps for other organizations interested in similar implementation strategies.

Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.

This study reports on the incidence of unintentional exposure to prescription and over-the-counter medications that are not properly stored out of reach of young children.

This announcement notifies health care practitioners of possible interference with medical alarms and patient monitoring systems caused by mobile radio transmitters.

The author presents a case analysis to illustrate common system errors in the use of intrapartum electronic fetal monitoring: inadequate knowledge, fear of conflict, and poor communication.

The investigators in this AHRQ-funded project offer insights from their experience in implementing computerized provider order entry (CPOE) in a geriatric care setting.

The authors found that an educational intervention and feedback improved nurses' bedside charting practices.

In this AHRQ-funded study, the investigators reviewed the medication management process for home care and developed several recommendations to improve safety.

This monthly selection of medication error reports provides examples from the field of potential errors and helpful tips on how to avoid similar mistakes.

This AHRQ–funded study retrospectively examined the failure rate of recommended laboratory surveillance for patients on specific chronic medications. Using claims data from two large health plans, the investigators selected 11 drugs and their recommended lab testing intervals to capture and analyze data. Results suggested that nearly half of those requiring a chronic medication were subject to a potential laboratory monitoring error per year. Discussion includes detailed presentation of the potential error rates and how they differed among specific drugs and lab tests. The authors conclude that the prevalence of inadequate laboratory monitoring should stimulate further research about its impact on several clinical outcomes.