Medication Errors

Warning labels on outpatient prescription vials not so great after all

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Everyone has seen them, I know you have. Those little colored labels that the pharmacy slaps on your bottle when you get a prescription: “May cause drowsiness”, “Avoid excess sun”, “Do not take aspirin products without doctor approval” and so on. There are a ton of them. I remember seeing them lined up in front of me when I was working retail. Sometimes it became a game to see how many you could fit on the bottle without covering up valuable information for the patient. I’ve also been in pharmacies where the warning labels were simply printed alongside the medication label.

Well, it appears that this tradition may not be the best way to warn patients about potential issues with their medication. I mean, who really reads those things anyway?

A small study recently published in the journal PLoS ONE took a look at these warning labels and determined that people really don’t pay attention. Not surprising.

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Medication reconciliation on an internal medicine unit in French hospital [Article]

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Interesting abstract from Presse Medicale (Paris, France) talking about medication reconciliation on an internal medicine unit in a French hospital. The authors found lots or discrepancies, which isn’t a surprise. They also found that pharmacists could help identify and correct many of the discrepancies, which also isn’t a surprise. Like many other articles I’ve read recently, … Read more

Article: The costs of adverse drug events in community hospitals

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The article below appeared in the March 2012 edition of Joint Commission Journal on Quality and Patient Safety – yes, that’s a real journal. I couldn’t make this stuff up – Anyway, there’s nothing new here, we all know that ADEs are expensive. How expensive? Well, the bottom line is that “ADEs were associated with an increased adjusted … Read more

Failure to use “low concentration” alerts properly leads to errors [ISMP Safety Alert]

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When I read the headline in the most recent ISMP Medication Safety Alert! – Smart pump custom concentrations without hard “low concentration” alerts – I didn’t really get it. So what if a smart pump doesn’t stop you from programming “low concentrations”? Well after reading through the article, and the examples, it made perfect sense. … Read more

Don’t confuse Durezol and Durasal (S.A.L.A.D.)

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PharmQD: “FDA is alerting pharmacists and other health care professionals of potential injury due to confusion between the FDA-approved eye medicine Durezol (difluprednate ophthalmic emulsion) 0.05% and the unapproved prescription topical wart remover Durasal (salicylic acid) 26%. There has been one report of serious injury when a pharmacist mistakenly gave an eye surgery patient Durasal, … Read more

High-Alert Medications Involved in Wrong-Drug Errors [Article]

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A recent article in Pharmacy Times outlines some interesting examples of Sound-Alike-Look-Alike-Drugs (SALAD) causing trouble in pharmacy. We’ve all seen them, and I’ve blogged about them before. Hydralazine and hydroxyzine represent a prototypical SALAD pair, but there are many others out there; ISMP’s list can be found here (PDF).

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Prevalence of medication administration errors in two medical units with automated prescription and dispensing [Article]

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From the Journal of the American Medical Informatics Association1. I was a little shocked by the number of errors, but as you can see in the abstract below, and in the title, the errors were during the administration phase of the medication use process. Seems a bit odd to look at medication errors during administration … Read more

Cool Pharmacy Technology–RevVac Syringe

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I suppose this could really be cool tech for nursing or lab, but I thought it was worth having a deeper look. The ReVac Retracting Safety Syring by Revolutions Medical “use a proprietary patented technology in which a vacuum causes the needle to retract into the barrel of the syringe or device after an injection … Read more