Medication Safety

Forcing re-entry of patient ID cuts wrong-patient errors

by

You know how websites make you double enter your email address and password when you sign up for a service? Well, apparently that’s not a bad system for making sure you have the right patient during order entry. You’d think we would have figured that out a while back, but then again this is healthcare … Read more

Prenteral nutrition error [from #ISMP]

by

From the latest ISMP Medication Safety Alert!, a mix up between an adult parenteral nutrition (PN) template in an electronic health record (#EHR) and one for pediatrics.

The big difference between these two is how you order electrolytes; it’s a really big difference.

The most shocking part of all this was that the error made it’s way through the physician that ordered it, a pharmacist that “entered the PN order” (I’m assuming in the compounding application), the “trained technician” that prepared it – missing the fact that the bag contained a whooping 2600mL of sterile water, the pharmacist that checked it, and finally the nurse that hung it. Swiss cheese anyone?

Read more

Warning labels on outpatient prescription vials not so great after all

by

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.

Read more

Cool Pharmacy Tech – Real time volume detection in syringes

by

I received the Tweet below last night from Denis Lebel. The link took me to a YouTube video that demonstrates the use of a camera and software to determine the volume inside a syringe. It’s really cool. I had an idea like this about 6-8 months ago. I talked it over with a colleague and … Read more

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

by

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

by

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

Physician dispensing, that’s some bad mojo right there

by

Physician dispensing is a hot topic for several reasons. And while I’m not opposed to the use of medication kiosks to dispense medications to patients, I believe that their use must be carefully defined and continuously monitored. As I said in a post in September 2010 “Under the right set of circumstances, and with thoughtful implementation, kiosks could free up pharmacists to spend more time with patients in emergency departments and urgent care clinics across the country. After all, don’t pharmacists argue for more clinical face time with patients and less association with the physical medication dispensing process? That’s what I’ve been hearing from pharmacists for years.” The key part of that quote is “under the right set of circumstances”. You cannot remove the pharmacist form the medication use process. It would be a mistake to do so, and I believe ultimately would lead to increased patient risk. I’ve worked in retail, long-term care, home infusion and acute care pharmacy, and let’s face it, physicians struggle at times to get things right. That’s why God made pharmacists. While I’m not naive enough to think that a pharmacist has to speak to each and every patient about every medication they use each time they receive it, I do think there should be some oversight of the process; regardless of the method of distribution.

Read more

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

by

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

ADR death statistics for the US, 1999-2006 [article]

by

Here’s an interesting article from the February 2012 issue of The Annals of Pharmacotherpy [Adverse Drug Reaction Deaths Reported in United States Vital Statistics, 1999-2006].1 The most commonly involved drug classes are no big surprise, but it was interesting to note that the incidence of ADR death changed with age, race, and urbanization. I suppose the … Read more

Med Adherence – Difference between prescribed and dosing histories [Article]

by

Annual Review of Pharmacology and Toxicology (2012 Feb 10;52:275-301. Epub 2011 Sep 19) – No big surprise here, but check out the graphs (posted below), especially the second one where you can see the effect poor compliance/adherence has on therapeutic concentration. Crazy.

Abstract

Satisfactory adherence to aptly prescribed medications is essential for good outcomes of patient care and reliable evaluation of competing modes of drug treatment. The measure of satisfactory adherence is a dosing history that includes timely initiation of dosing plus punctual and persistent execution of the dosing regimen throughout the specified duration of treatment. Standardized terminology for initiation, execution, and persistence of drug dosing is essential for clarity of communication and scientific progress. Electronic methods for compiling drug dosing histories are now the recognized standard for quantifying adherence, the parameters of which support model-based, continuous projections of drug actions and concentrations in plasma that are confirmable by intermittent, direct measurements at single time points. The frequency of inadequate adherence is usually underestimated by pre-electronic methods and thus is clinically unrecognized as a frequent cause of failed treatment or underestimated effectiveness. Intermittent lapses in dosing are potential sources of toxicity through hazardous rebound effects or recurrent first-dose effects.

Read more