Tag: Medication Safety
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High-Alert Medications Involved in Wrong-Drug Errors [Article]
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]
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 when talking about automated prescribing and dispensing. I’m sure there is an explanation in the full article. However that requires a subscription. Interesting nonetheless:
Abstract
Objective To identify the frequency of medication administration errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets.Design Prospective observational study conducted within two clinical units of the Gastroenterology Department in a 1537-bed tertiary teaching hospital in Madrid (Spain).
Measurements Medication errors were measured using the disguised observation technique. Types of medication errors and their potential severity were described. The correlation between potential risk factors and medication errors was studied to identify potential causes.
Results In total, 2314 medication administrations to 73 patients were observed: 509 errors were recorded (22.0%)—68 (13.4%) in preparation and 441 (86.6%) in administration. The most frequent errors were use of wrong administration techniques (especially concerning food intake (13.9%)), wrong reconstitution/dilution (1.7%), omission (1.4%), and wrong infusion speed (1.2%). Errors were classified as no damage (95.7%), no damage but monitoring required (2.3%), and temporary damage (0.4%). Potential clinical severity could not be assessed in 1.6% of cases. The potential risk factors morning shift, evening shift, Anatomical Therapeutic Chemical medication class antacids, prokinetics, antibiotics and immunosuppressants, oral administration, and intravenous administration were associated with a higher risk of administration errors. No association was found with variables related to understaffing or nurse’s experience.
Conclusions Medication administration errors persist in units with automated prescription and dispensing. We identified a need to improve nurses’ working procedures and to implement a Clinical Decision Support tool that generates recommendations about scheduling according to dietary restrictions, preparation of medication before parenteral administration, and adequate infusion rates.
1. J Am Med Inform Assoc. 2012 Jan 1;19(1):72-8. Epub 2011 Sep 2.
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Wanna’ tell the FDA about drug shortages? Here’s how
Here’s the contents of a email I received today from ASHP in regards to drug shortages and the FDA:
The Food and Drug Administration Wants to Hear How Drug Shortages Impact Patients
The Food and Drug Administration has opened a comment period to gain insight about the causes and impact of drug shortages. The agency is seeking feedback as a follow up to a public workshop on the impact of shortages.
You know first-hand the devastating effect that drug shortages are having on patient care. Today, ASHP’s Drug Shortages Resource Center lists 208 shortages. That’s nearly the same number of shortages that were reported in all of 2010.
This is your chance to speak up.
Write a letter to the FDA that describes your experiences and challenges managing drug shortages. Here’s what you should include:
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Impact on patient care. Share examples from your practice site, such as patients who’ve had to delay care or who’ve experienced adverse affects from second-line therapies.
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Impact on pharmacy department operations: Discuss how the time spent researching availability of drug products and the redeployment of pharmacists from patient care roles affects the pharmacy department.
Be sure to ask your colleagues in the pharmacy department as well as your nursing and physician colleagues to join you. Enlist your patients as well. Every voice counts!
The deadline to submit comments is December 23, 2011. You can post comments on www.regulations.gov or send comments to the Division of Dockets Management (HFA-305), Food and Drug Administration, 5630 Fishers Lane, Rm.1061, Rockville, MD 20852. See the Federal Register notice for more details.
Your input and expertise are not only welcome, they are essential to achieving a solution to this critical issue.
Use the resources below to familiarize yourself with ASHP’s messages on drug shortages.
- ASHP Statement for the Record House Energy and Commerce Committee Subcommittee on Health Hearing: "Examining the Increase in Drug Shortages" [PDF]
- Drug Shortages FAQs
- Drug Shortages Threaten Patient Care
- Drug Shortages Resource Center
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Fun with Lugol’s solution…not really
A recent ISMP Medication Safety Alert shared various errors that have occurred with Lugol’s solution over the ages. Lugol’s solution is a concentrated liquid form of potassium iodide and iodine known for its use in the treatment of hyperthyroidism. It’s also a dangerous drug because it’s typically dosed in drops, not mL’s.
Anyway, the ISMP alert shared several examples of oral overdoses with Lugol’s solution secondary to confusion between drops and mL’s. However, mixed in with all the “typical†errors, was the little gem below. Even though the error is more than a decade old, I can’t help but wonder “what the heck were they thinking!â€. By the way, my initial read through had me thinking cursive “OS†(oculus sinister, i.e. LEFT eye). With that said, I wouldn’t have actually dispensed it because nothing else on the prescription fits.
One of the errors reported more than a decade ago involved an order to administer 10 drops of Lugol’s solution mixed with "OJ" (orange juice), but nurses misinterpreted "OJ" as OD (right eye). The patient received several doses of Lugol’s solution in his right eye. The error was identified when the patient complained to the physician about how painful the eye drops were.
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Cool Pharmacy Technology–RevVac Syringe
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 is administered or blood is drawn.â€
According to the Revolutions Medical website “[t]he RevVacâ„¢ Safety Syringe and Phlebotomy (blood drawing) Device operate the same as a standard syringe and device. No additional training, skills, or procedures are necessary. The both products work on a vacuum principle, where pressing the plunger in them creates a vacuum. When the plunger reaches the bottom, the needle is captured. A further push on the plunger breaks the seal, and the needle retracts into the plunger barrel. The vacuum is maintained, so the needle cannot be removed from the plunger.â€
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Canada calls for national drug shortage registry [article]
The Canadian Pharmacist Association is looking for a way to track drug shortages. They would like to get drug manufactures and hospitals to participate in a national reporting system. It’s a great idea and one that I think could provide value.
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Technology and pharmacist impact on medication adherence
mobihealthnews: “According to a recent study by Express Scripts, Americans might be wasting as much as $258 billion annually by not taking their prescribed medications. Missed doses can lead to emergency room visits and doctors’ visits, which could be prevented if medication adherence was improved. The Express Scripts study found that more than half of people who believe they take their medications properly are not, according to a report in USA Today.
A similar study conducted by NEHI found that poor medication adherence results in illnesses and ensuing treatments that cost some $290 billion in unnecessary spending each year, $100 billion of that in avoidable hospitalizations alone.
Two members of Congress recently introduced bills to allow Medicare reimbursement for more patients to sit down with therapists one-on-one and equip patients with pill boxes or text message services that help patients become more adherent, the USA Today report said.
The Toronto University College of Pharmacy conducted a study that found medication therapy saved about $93.78 per patient annually in a study of 23,798 people, USA Today reports.â€
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The tail wagging the dog
WSJ: “The Food and Drug Administration said Tuesday that it will require some painkiller manufacturers to produce new educational tools in an effort to quell prescription-drug abuse.The requirements will affect makers of long-acting and extended-release opioids, which include oxycodone, morphine and methadone.
Letters have been sent to manufacturers of the drugs describing the medication guides and tools for physician training that are now required, FDA Commissioner Margaret Hamburg said. The FDA will approve the materials, which will also be accredited by professional physician-education providers, she said, a step meant to combat bias in the materials.â€
Oh. My. Gosh. Let me see if I can wrap my brain around this. The FDA is going to require that manufacturers of certain “painkillers†tell physicians how to properly use the drugs instead of requiring physicians to read the literature and do exactly what they’re trained and paid to do. Crud, it’s nothing a good pharmacist couldn’t fix. Why doesn’t the FDA simply require physicians to run these same prescriptions through a pharmacist for approval or give pharmacist prescriptive authority instead. It makes a lot more sense than putting the manufacturers in charge of the asylum. I would be utterly embarrassed if a drug manufacturer had to tell me how to properly use a drug because I couldn’t get it right. I think the healthcare system has officially reached a new low. Unfortunately this ain’t no limbo contest.
