Development and implementation of autoverification standardization in the adult and pediatric emergency department.

Disclaimer: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

A Data-Driven Approach to Evaluate Barcode-Assisted Medication Preparation Alerts at a Large Academic Medical Center.

Background: The purpose of this study was to develop a data-driven process to analyze barcode-assisted medication preparation alert data with a goal of minimizing inaccurate alerts.

Methods: Medication preparation data for the prior three-month period was obtained from an electronic health record system. A dashboard was developed to identify recurrent, high-volume alerts and associated medication records.

Analysis of medication-related triggers to determine adverse drug events.

Purpose: Voluntary event reporting systems continue to be the most common method used to identify adverse events in most US hospitals; however, this method fails to capture more than 90% of adverse drug events (ADEs). The purpose of this study is to examine which medication-related triggers have the highest positive predictive values (PPV) for detecting ADEs at a large academic medical centre.

Methods: A 1-year, single-centre, retrospective quality improvement study was conducted to assess the PPV of four medication-related triggers: flumazenil, naloxone, glucose <70 mg/dL or dextrose 50%.

Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology.

Purpose: The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach.

Methods: An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores.

Current state of opioid stewardship.

Purpose: The opioid epidemic continues to result in significant morbidity and mortality even within hospitals where opioids are the second most common cause of adverse events. Opioid stewardship represents one model for hospitals to promote safe and rational prescribing of opioids to mitigate preventable adverse events in alliance with new Joint Commission standards. The purpose of this study was to identify the prevalence of current hospital practices to improve opioid use.

The Effect of Performance Transparency on Adherence to Barcode Scanning During Order Preparation in an Adult Inpatient Satellite Pharmacy.

The aim of this study was to investigate the effect of performance transparency and individualized feedback on pharmacy technician compliance with barcode verification technology during inpatient order preparation. Following the incorporation of barcode scanning technology into the workflow of pharmacy staff, a multiphasic intervention was employed to promote its use. The intervention included verbal feedback and publically posting performance metrics to increase accountability.

A Multi-hospital Before-After Observational Study Using a Point-Prevalence Approach with an Infusion Safety Intervention Bundle to Reduce Intravenous Medication Administration Errors.

Introduction: We previously found a high rate of errors in the administration of intravenous medications using smart infusion pumps.

Objectives/design: An infusion safety intervention bundle was developed in response to the high rate of identified errors. A before-after observational study with a prospective point-prevalence approach was conducted in nine hospitals to measure the preliminary effects of the intervention.

Medication Errors and Trainees: Advice for Learners and Organizations.

Limited information exists regarding medication errors and trainees (students or residents). Yet during the experiential education component of their training, learners are expected to assume significant responsibilities in the medication use process. This commentary addresses both trainees and organization leaders on medication safety practices and the incorporation of learners into the organization's medication safety culture.