John S. Clark

Computer based medication error reporting: insights and implications

Background: Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports. Objective: To assess the accuracy and define the epidemiology of medication error reports. Design, setting, and patients: A retrospective cohort study of 581 error reports containing 1010 medication errors reported between July 2001 and January 2003 at a large academic children’s institution. Main outcome measures: Correct classification and types of medication errors. Results: Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non-descript “other” category on the reporting tool (such as “Prescribing other”) which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%). Conclusions: Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer.

Decreasing errors in pediatric continuous intravenous infusions

Objective: To evaluate the effect of a Web-based calculator and decision-support system on infusion ordering errors and to estimate error frequency in pharmacy infusion preparation. Design: Data on ordering error frequency and typology were collected before and after implementation of an online infusion ordering system. Data on pharmacy preparation errors of infusions were collected. Setting: A childrens hospital at an academic medical center. Patients: None. Data were abstracted from infusion orders. Interventions: Introduction of a voluntary-use Web-based calculator into infusion ordering workflow. Observation only. Main Outcome measures: Number and type of errors in handwritten and calculator-generated orders. Number and type of errors in pharmacy infusion preparation. Results: Before calculator deployment, 129 sequential handwritten infusion orders were collected over 5 weeks. After deployment, of 162 sequential infusion orders, 88% (142) were calculator-generated. Calculator-generated infusion orders contained 83% fewer (p < .001) orders containing one or more errors than handwritten orders. Calculator-generated orders contained no high-risk errors (incorrect decimal, dose, or unit of measure) when compared with handwritten orders and were associated with fewer pharmacy interventions. In 118 sequential pharmacy infusion preparations over 4 wks, there were no errors observed. Conclusion: A Web-based calculator reduced significantly the total number of errors and eliminated all high-risk errors in the prescribing process for continuous pediatric infusions. With no observed errors in pharmacy preparation, this study provides data to support the use of computerized ordering as an independent safe and viable method for ordering continuous pediatric infusions.

Prescribing errors in a pediatric emergency department.

Objectives: To determine the frequency, prescriber, and type of prescribing errors in written in-house orders and ambulatory prescriptions in a pediatric emergency department (PED). Methods: A 17-day retrospective chart review and a 6-month retrospective ambulatory prescription review in a PED for medications with weight-based dosing. Orders and prescriptions were checked for prescriber identification number, route, weight-based target dose in milligrams per kilogram, frequency, correct dosing, and drug allergies. Narcotics were excluded from the prescription analysis. Results: Forty-seven (12.5%) of 377 in-house orders and 37 (19.4%) of 191 individual charts contained at least 1 error: 4 (1.1%) orders contained an incorrect dose, 41 (10.8%) were written incorrectly, and 2 (0.5%) contained an incorrect dose and were written incorrectly. Thirty (4.3%) of 696 ambulatory prescriptions contained 1 error: 14 (2.0%) contained an incorrect dose, and 16 (2.3%) were written incorrectly. Pediatric postgraduate year-3 residents had the highest in-house order incorrect dose error rate (1 of 29 orders or 3.5%), and ED pediatric postgraduate year-2 residents had the highest ambulatory prescription incorrect dose error rate (6 of 66 prescriptions or 9.1%). Pediatric ED attending physicians had the highest error rates for writing orders and prescriptions incorrectly, 25% (3 of 12) and 9.7% (3 of 31), respectively. Antibiotics, analgesics, and narcotics were most often involved in errors. Conclusions: Prescribing errors are common in both written in-house orders and ambulatory prescriptions in a PED. Targeting safety interventions toward groups with less practice in prescribing pediatric doses and reeducating groups on safe medication writing techniques could decrease this error rate.

Improving student education and patient care through an innovative introductory pharmacy practice experience

![Figure][1] The standards of the Accreditation Council for Pharmacy Education (ACPE) for doctor of pharmacy programs require pharmacy curricula to provide students with introductory pharmacy practice experiences (IPPEs), which are defined as “practice experiences offered in various

Pharmacy practice model change: Lean thinking provides a place to start

In response to recent changes in pharmacy practice, the American Society of Health-System Pharmacists (ASHP) and the ASHP Research and Education Foundation cosponsored the Pharmacy Practice Model Initiative (PPMI).[1][1] The goals of the PPMI are to update the practice model structure to improve

Using a novel approach to collect, disseminate, and assess residency application materials

PURPOSE The implementation of a Web-based tool for pharmacy resident application submission and management in a teaching-affiliated institution is described. SUMMARY To improve and increase the efficiency of its residency application submission and management process, pharmacy leadership at the University of Michigan abandoned the traditional paper-based process for selecting and communicating with residency candidates for an onsite interview. CTools, a customized version of the open-source Sakai learning content management system, was used to construct the pharmacy residency application and evaluation site. At its core, Sakai is a framework that allows a community of educators and programmers to develop tools that aid in the management, delivery, and communication related to learning and collaboration. The CTools site for residency recruitment was configured to allow candidates, including those not affiliated with the university, to request access to the application site and to create an account. In addition, the site allows preceptors and the residency advisory committee (RAC) members to review submitted application materials. The CTools site uses three basic learning management system (LMS) modules: announcements, assignments, and resources. The announcements module provides an easy way to distribute information to the candidates. The assignment module is a secure area where candidate application materials are compiled into folders and made available to those staff members who need to review the application. The resources module is a repository of required residency documents and forms. CONCLUSION An institution transitioned from its traditional manual process to a Web-based tool to collect and share residency application materials in a more streamlined fashion.

Preparation times and costs for various solutions used for continuous renal replacement therapy

Purpose Results of a study to determine time and cost requirements for final preparation of continuous renal replacement therapy (CRRT) products are reported. Methods A 3‐phase observational study was conducted at a tertiary care university hospital to evaluate costs associated with manual addition of phosphate and/or potassium to 3 commercial 5‐L CRRT products. In the first phase of the study, pharmacy workflow processes for solution preparation were established; in the second phase, pharmacist and pharmacy technician time spent in the CRRT workflow and all materials used were observed and recorded. In the third phase, time and personnel requirements were analyzed in economic terms to estimate final preparation costs. Results Through direct observation over 35 days, the CRRT workflow was observed and work times recorded for 511 bag preparations. The main cost contributors were the base CRRT solution and electrolyte additive prices. Technician compounding time differed substantially by solution brand and the need for electrolyte addition. Pharmacist verification time did not differ meaningfully by product. Conclusion Preparation and verification of premade CRRT solutions that contained physiological electrolyte concentrations required less technician and pharmacist time than solutions that needed addition of electrolytes in the pharmacy. Personnel costs, which were a small part of the total cost of dispensed CRRT bags, were higher for technicians than pharmacists. The baseline costs of the solutions and the electrolyte additives, if needed, were the main contributors to total cost.

Update on preparation of solutions for continuous renal replacement therapy

We recently published a report of pharmacy costs associated with customizing and compounding continuous renal replacement therapy (CRRT) solutions.[1][1] The major contributor to the time required to compound the phosphate-containing solution (Phoxillum, Baxter Healthcare) compared with solutions