The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

Objective: To use the electronic prescribing system to identify how prescribers have responded to the duplicate 'Anticoagulant Alert' and the extent to which the system has prevented unintentional prescription of Low Molecular Weight Heparins (LMWHs) to patients prescribed Direct Acting Anticoagulants (DOACs). To determine the clinical appropriateness of the actions taken by the prescriber following the alert override and the impact this has on patient safety.

Material And Methods: A retrospective service evaluation was conducted to determine the impact of a duplicate 'Anticoagulant Alert' on the prevention of prescription of LMWHs to patients already prescribed DOACs at a 950-bed acute teaching hospital in the UK.

Magnitude of error: a review of wrong dose medication incidents reported to a UK hospital voluntary incident reporting system.

Objectives: Our aim was to review medication-related incidents reported to a hospital voluntary incident reporting system to identify and quantify the magnitude of wrong dose errors.

Methods: The study was a retrospective review of medication-related incidents reported over a 7-year period at a large acute teaching hospital in the UK, providing secondary and tertiary care for a range of clinical specialties. Medication-related incident reports submitted from all clinical settings were reviewed.

The Problem with Amphotericin.

Patient harm from inadvertent administration of amphotericin B (Fungizone™) instead of liposomal amphotericin (AmBisome) has been described in the literature and has been the subject of patient safety alerts in the UK. Safe use of intravenous amphotericin depends on the knowledge and awareness of practitioners of the availability and differences between the different presentations of intravenous amphotericin. Knowledge is a weak barrier to error.

Evaluation of the practice of dose-rounding in paediatrics.

Objectives: To investigate the rounding of prescribed drug doses for paediatric administration.

Methods: A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes.

Preventing Hypoglycemia Following Treatment of Hyperkalemia in Hospitalized Patients.

Hypoglycemia is a serious complication following treatment of hyperkalemia with intravenous insulin. The aims of this study were to determine the incidence of hypoglycemia (≤3.9 mmol/l, 70 mg/dL) and severe hypoglycemia (<3.

Iatrogenic magnesium toxicity following intravenous infusion of magnesium sulfate: risks and strategies for prevention.

A 65-year-old man being treated with radiotherapy and chemotherapy for recurrent colonic adenocarcinoma was admitted for management of hypokalaemia and hypomagnesaemia secondary to diarrhoea. He was treated with intravenous infusions of potassium chloride and magnesium sulfate. Following an infusion of magnesium sulfate, he experienced a sudden neurological deterioration.

A pre-postintervention study to evaluate the impact of dose calculators on the accuracy of gentamicin and vancomycin initial doses.

Objectives: Gentamicin and vancomycin are narrow-therapeutic-index antibiotics with potential for high toxicity requiring dose individualisation and continuous monitoring. Clinical decision support (CDS) tools have been effective in reducing gentamicin and vancomycin dosing errors. Online dose calculators for these drugs were implemented in a London National Health Service hospital.

Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.

Background: Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these.

Methods: We used a mixed methods, controlled before and after design.

Risk of medication safety incidents with antibiotic use measured by defined daily doses.

Background: Medication incidents (MIs) account for 11.3 % of all reported patient-safety incidents in England and Wales. Approximately one-third of inpatients are prescribed an antibiotic at some point during their hospital stay.