Michael R. Cohen

Why error reporting systems should be voluntary

Doctors, nurses, and pharmacists share a common goal of identifying medical error, understanding its causes, and making system wide changes to reduce medical risks. Error reporting is a primary component of that goal. Recent public policy discussions in the United States have explored the risks and benefits of mandatory and voluntary reporting systems to identify the most effective ways to promote candid disclosure of medical error. 1 2 The Institute for Safe Medication Practices has been a strong and vocal proponent of non-punitive, voluntary error reporting programmes.3nnNational models exist in the US for both mandatory and voluntary error reporting programmes. The Medication Errors Reporting Program, operated by the United States Pharmacopoeia in cooperation with the Institute for Safe Medication Practices, is a confidential, voluntary medication error reporting programme. About 1000 completed error reports are received each year from clinicians and state boards, but more important than the number of reports is their quality. Each report provides a great deal of information which has allowed us to identify the wide scope of medication safety problems and explore their system based causes. Practical recommendations to prevent reoccurrence are made through a widely distributed newsletter and other educational efforts.nnThe information derived …

Dabigatran, bleeding, and the regulators

Thomas J Moore and colleagues highlight the differences in how US and European regulators managed the safety problems of the new anticoagulant dabigatran and ask both to think again and mandate plasma monitoring of dabigatran

Telomerase activity in patients with transitional cell carcinoma

Telomerase activity is not detectable in normal cells, and their telomers shorten until the chromosome is unable to replicate. Immortal cells have short but stable chromosomes and increased telomerase activity. Transitional cell carcinoma (TCC) has only a few useful markers of diagnostic or prognostic importance. The objective of this study was to determine whether there was a correlation between telomerase activity and the grade or stage of TCC, and whether the enzymes activity could serve as a biochemical marker of this tumor.

Systems Factors in the Reporting of Serious Medication Errors in Hospitals

Underreporting of medication errors poses a threat to quality improvement initiatives. Hospital risk management programs encourage medication error reporting for effective management of systems failures. This study involved a survey of 156 medical-surgical hospitals in the United States to evaluate systems factors associated with the reporting of serious medication errors. Prior to controlling for bed size, a multivariate logistic regression model showed increased reporting of medication errors in hospitals with 24-h pharmacy services, presumably because of better error reporting systems. When number of occupied beds was included, the final model demonstrated bed size to be the only statistically significant factor. Increased reporting rates for serious medication errors warrant further evaluation, but higher error reporting may paradoxically indicate improved error surveillance. Results suggest that increased availability of pharmacist services results in opportunities for more diligent systematic efforts in detecting and reporting medication errors, which should lead to improved patient safety.

Pain Scales Don't Weigh Every Risk

The risk of patients receiving opioids without adequate monitoring and resulting in adverse outcomes has been noted by the Institute for Safe Medication Practices. More aggressive opioid analgesia often is clinically indicated, but it is not without risk. Adverse drug events due to opioids have increased with the recent adoption of pain management standards by the Joint Commission on Accreditation of Healthcare Organizations. The implications of this are discussed and a specific safe practice recommendation is provided.

Accidental intramuscular injection of mechlorethamine.

A 55‐year‐old man with chronic, active, diffuse psoriasis was accidentally given 30 mg of mechlorethamine deep into the buttock muscles. About 5 hours after the intramuscular (IM) mechlorethamine injection, 1/6 M sodium thiosulfate was infused around the intramuscular site. Although systemic responses to the mechlorethamine developed, the expected muscular and adjacent skin destruction did not occur. Instead, IM mechlorethamine induced only minimal local tenderness.

Dispensing the Wrong Medication

Abstract A 77-year-old woman with a history of glaucoma was hospitalized with metabolic acidosis, electrolyte abnormalities, and changes in her mental status. 1 Upon entering the hospital, she was given aceta- zolamide (Diamox) 250xa0mg daily. Within a few days, she experienced lethargy and her blood glucose levels fell to 20xa0mg per deciliter. Even though intravenous glucose was administered, the patient died on the 14th day of her hospitalization. Investigation into the cause of the hypoglycemia revealed that the patient had been mistakenly given acetohexamide (Dymelor).

Preventing Errors with Neuromuscular Blocking Agents

Recommendations address reduction of risk of harm from neuromuscular blocking agents, hihg-alert drugs for which misuse can lead to catastrophic injuries or death.

Purpose of Medication Will Reduce Errors

Abstract: Prescribers sometimes think of prescribing one medication but mistakenly prescribe another. At other times, pharmacists misread prescriptions and dispense the wrong drug. Sometimes patients forget which medication they are supposed to take and choose the wrong one from their array of prescription containers. There is a simple way to greatly lower the chance of these three errors: prescribers should indicate the purpose of the medication on the prescription order and pharmacists should place this information on the label.

The Additional Value of Free Prostate Specific Antigen to the Battery of Age-Dependent Prostate-Specific Antigen, Prostate-Specific Antigen Density and Velocity

This study describes the value of using the fraction of free prostate-specific antigen as a further marker in the early detection of prostate cancer. This newly introduced marker is compared to the usual battery of age-dependent total prostate-specific antigen, prostate-specific antigen density (microg/l x g tissue) and prostate-specific antigen velocity (microg/l x year). Determination of total prostate-specific antigen and free prostate-specific antigen was performed on fresh serum samples obtained from 3470 symptomatic patients aged 45-80 attending the Urology Clinics, or their General Practitioners. Among them, 310 patients had total prostate-specific antigen above the age-dependent cut-off, and/or free/total prostate-specific antigen under 11%, with different prostate-specific antigen densities and velocities. Only 147 patients complied to undergo biopsy: in 72 of those patients, benign prostatic disease was histologically confirmed, while in 75 patients primary prostate cancer was histologically confirmed. Total and free prostate-specific antigen levels were determined using the third generation DPCs prostate-specific antigen assay performed on the Immulite automated immunoassay instrument. Total prostate-specific antigen age reference values were adopted from Oesterling et al. (J Am Med Ass 1993; 270:860-4); the prostate-specific antigen density was considered suspicious of prostate cancer if it was greater than 0.15 microg/l prostate-specific antigen per gram tissue (Seaman et al. Urol Clin N Am 1993; 20:653); prostate-specific antigen velocity greater than 0.75 microg/l x year (Carter et al., J Am Med Ass 1992; 267:215) was considered suspicious for prostate cancer. Of the 147 patients, 75 had prostate cancer and 72 had benign prostatic hypertrophy. The difference between prostate cancer and benign prostatic hypertrophy was significantly reflected only by free/total prostate-specific antigen and prostate-specific antigen velocity. These parameters also provided the best sensitivity and specificity. Only these parameters proved to be significant when using a backwards logistic regression model (prostate-specific antigen velocity, p = 0.007 odds ratio 2.782; free/total prostate-specific antigen %, p = 0.016 odds ratio 2.678). Combinations of various parameters became significant when including free/total prostate-specific antigen, increasing prostate cancer detection to 88%. We conclude that free/total prostate-specific antigen is the most significant among prostate-specific antigen quantities (total age-dependent prostate-specific antigen, prostate-specific antigen density and prostate-specific antigen velocity). Adding this parameter to other prostate-specific antigen parameters improves the discrimination between prostate cancer and benign prostatic hypertrophy for the population at risk.