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Smashing the strict hierarchy: three cases of clinical decision support malfunctions involving carvedilol.
Wright A, Wright AP, Aaron S, Sittig DF
(2018) J Am Med Inform Assoc 25: 1552-1555
MeSH Terms: Adrenergic alpha-1 Receptor Antagonists, Adrenergic beta-Antagonists, Carvedilol, Decision Support Systems, Clinical, Electronic Health Records, Humans, Knowledge Management, Medication Errors, Terminology as Topic, Vocabulary, Controlled
Show Abstract · Added November 7, 2019
Clinical vocabularies allow for standard representation of clinical concepts, and can also contain knowledge structures, such as hierarchy, that facilitate the creation of maintainable and accurate clinical decision support (CDS). A key architectural feature of clinical hierarchies is how they handle parent-child relationships - specifically whether hierarchies are strict hierarchies (allowing a single parent per concept) or polyhierarchies (allowing multiple parents per concept). These structures handle subsumption relationships (ie, ancestor and descendant relationships) differently. In this paper, we describe three real-world malfunctions of clinical decision support related to incorrect assumptions about subsumption checking for β-blocker, specifically carvedilol, a non-selective β-blocker that also has α-blocker activity. We recommend that 1) CDS implementers should learn about the limitations of terminologies, hierarchies, and classification, 2) CDS implementers should thoroughly test CDS, with a focus on special or unusual cases, 3) CDS implementers should monitor feedback from users, and 4) electronic health record (EHR) and clinical content developers should offer and support polyhierarchical clinical terminologies, especially for medications.
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10 MeSH Terms
Reducing Adverse Drug Events: The Need to Rethink Outpatient Prescribing.
Kessler C, Ward MJ, McNaughton CD
(2016) JAMA 316: 2092-2093
MeSH Terms: Drug-Related Side Effects and Adverse Reactions, Humans, Medication Errors, Outpatients
Added April 6, 2017
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4 MeSH Terms
Characteristics associated with postdischarge medication errors.
Mixon AS, Myers AP, Leak CL, Lou Jacobsen JM, Cawthon C, Goggins KM, Nwosu S, Schildcrout JS, Schnelle JF, Speroff T, Kripalani S
(2014) Mayo Clin Proc 89: 1042-51
MeSH Terms: Acute Coronary Syndrome, Cognition Disorders, Depression, Female, Health Literacy, Heart Failure, Humans, Logistic Models, Male, Marital Status, Medication Adherence, Medication Errors, Middle Aged, Patient Discharge, Prospective Studies, Social Support
Show Abstract · Added January 20, 2015
OBJECTIVE - To examine the association of patient- and medication-related factors with postdischarge medication errors.
PATIENTS AND METHODS - The Vanderbilt Inpatient Cohort Study includes adults hospitalized with acute coronary syndromes and/or acute decompensated heart failure. We measured health literacy, subjective numeracy, marital status, cognition, social support, educational attainment, income, depression, global health status, and medication adherence in patients enrolled from October 1, 2011, through August 31, 2012. We used binomial logistic regression to determine predictors of discordance between the discharge medication list and the patient-reported list during postdischarge medication review.
RESULTS - Among 471 patients (mean age, 59 years), the mean total number of medications reported was 12, and 79 patients (16.8%) had inadequate or marginal health literacy. A total of 242 patients (51.4%) were taking 1 or more discordant medication (ie, appeared on either the discharge list or patient-reported list but not both), 129 (27.4%) failed to report a medication on their discharge list, and 168 (35.7%) reported a medication not on their discharge list. In addition, 279 participants (59.2%) had a misunderstanding in indication, dose, or frequency in a cardiac medication. In multivariable analyses, higher subjective numeracy (odds ratio [OR], 0.81; 95% CI, 0.67-0.98) was associated with lower odds of having discordant medications. For cardiac medications, participants with higher health literacy (OR, 0.84; 95% CI, 0.74-0.95), with higher subjective numeracy (OR, 0.77; 95% CI, 0.63-0.95), and who were female (OR, 0.60; 95% CI, 0.46-0.78) had lower odds of misunderstandings in indication, dose, or frequency.
CONCLUSION - Medication errors are present in approximately half of patients after hospital discharge and are more common among patients with lower numeracy or health literacy.
Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
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16 MeSH Terms
Pharmacokinetics and pharmacodynamics of imipenem and meropenem in critically ill patients treated with continuous venovenous hemodialysis.
Afshartous D, Bauer SR, Connor MJ, Aduroja OA, Amde M, Salem C, Groszek JJ, Fissell WH
(2014) Am J Kidney Dis 63: 170-1
MeSH Terms: Anti-Bacterial Agents, Critical Illness, Drug Dosage Calculations, Female, Gram-Negative Bacterial Infections, Humans, Imipenem, Male, Medication Errors, Meropenem, Metabolic Clearance Rate, Middle Aged, Renal Dialysis, Thienamycins
Added February 25, 2014
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14 MeSH Terms
Applying bar code medication administration to make a difference in adverse drug events with potential for harm: lessons learned.
FitzHenry F, Wells N, Doran J, Hughart K, Levy M, Doulis J
(2013) Comput Inform Nurs 31: 457-62
MeSH Terms: Drug Therapy, Drug-Related Side Effects and Adverse Reactions, Electronic Data Processing, Humans, Medication Errors, Patient Safety
Added March 7, 2014
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6 MeSH Terms
Inappropriate medication prescriptions in elderly adults surviving an intensive care unit hospitalization.
Morandi A, Vasilevskis E, Pandharipande PP, Girard TD, Solberg LM, Neal EB, Koestner T, Torres RE, Thompson JL, Shintani AK, Han JH, Schnelle JF, Fick DM, Ely EW, Kripalani S
(2013) J Am Geriatr Soc 61: 1128-34
MeSH Terms: APACHE, Aged, Comorbidity, Female, Humans, Inappropriate Prescribing, Intensive Care Units, Male, Medication Errors, Middle Aged, Patient Discharge, Poisson Distribution, Polypharmacy, Prospective Studies, Risk Factors, Severity of Illness Index, Survivors
Show Abstract · Added September 23, 2015
OBJECTIVES - To determine types of potentially (PIMs) and actually inappropriate medications (AIMs), which PIMs are most likely to be considered AIMs, and risk factors for PIMs and AIMs at hospital discharge in elderly intensive care unit (ICU) survivors.
DESIGN - Prospective cohort study.
SETTING - Tertiary care, academic medical center.
PARTICIPANTS - One hundred twenty individuals aged 60 and older who survived an ICU hospitalization.
MEASUREMENTS - Potentially inappropriate medications were defined according to published criteria; a multidisciplinary panel adjudicated AIMs. Medications from before admission, ward admission, ICU admission, ICU discharge, and hospital discharge were abstracted. Poisson regression was used to examine independent risk factors for hospital discharge PIMs and AIMs.
RESULTS - Of 250 PIMs prescribed at discharge, the most common were opioids (28%), anticholinergics (24%), antidepressants (12%), and drugs causing orthostasis (8%). The three most common AIMs were anticholinergics (37%), nonbenzodiazepine hypnotics (14%), and opioids (12%). Overall, 36% of discharge PIMs were classified as AIMs, but the percentage varied according to drug type. Whereas only 16% of opioids, 23% of antidepressants, and 10% of drugs causing orthostasis were classified as AIMs, 55% of anticholinergics, 71% of atypical antipyschotics, 67% of nonbenzodiazepine hypnotics and benzodiazepines, and 100% of muscle relaxants were deemed AIMs. The majority of PIMs and AIMs were first prescribed in the ICU. Preadmission PIMs, discharge to somewhere other than home, and discharge from a surgical service predicted number of discharge PIMs, but none of the factors predicted AIMs at discharge.
CONCLUSION - Certain types of PIMs, which are commonly initiated in the ICU, are more frequently considered inappropriate upon clinical review. Efforts to reduce AIMs in elderly ICU survivors should target these specific classes of medications.
© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
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17 MeSH Terms
Adverse drug events during AKI and its recovery.
Cox ZL, McCoy AB, Matheny ME, Bhave G, Peterson NB, Siew ED, Lewis J, Danciu I, Bian A, Shintani A, Ikizler TA, Neal EB, Peterson JF
(2013) Clin J Am Soc Nephrol 8: 1070-8
MeSH Terms: Acute Kidney Injury, Adult, Aged, Biomarkers, Creatinine, Drug Dosage Calculations, Drug-Related Side Effects and Adverse Reactions, Female, Glomerular Filtration Rate, Hospitalization, Humans, Hypotension, Inappropriate Prescribing, Kidney, Linear Models, Logistic Models, Male, Medication Errors, Middle Aged, Multivariate Analysis, Risk Factors, Tennessee, Time Factors, Treatment Failure
Show Abstract · Added August 21, 2013
BACKGROUND AND OBJECTIVES - The impact of AKI on adverse drug events and therapeutic failures and the medication errors leading to these events have not been well described.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS - A single-center observational study of 396 hospitalized patients with a minimum 0.5 mg/dl change in serum creatinine who were prescribed a nephrotoxic or renally eliminated medication was conducted. The population was stratified into two groups by the direction of their initial serum creatinine change: AKI and AKI recovery. Adverse drug events, potential adverse drug events, therapeutic failures, and potential therapeutic failures for 148 drugs and 46 outcomes were retrospectively measured. Events were classified for preventability and severity by expert adjudication. Multivariable analysis identified medication classes predisposing AKI patients to adverse drug events.
RESULTS - Forty-three percent of patients experienced a potential adverse drug event, adverse drug event, therapeutic failure, or potential therapeutic failure; 66% of study events were preventable. Failure to adjust for kidney function (63%) and use of nephrotoxic medications during AKI (28%) were the most common potential adverse drug events. Worsening AKI and hypotension were the most common preventable adverse drug events. Most adverse drug events were considered serious (63%) or life-threatening (31%), with one fatal adverse drug event. Among AKI patients, administration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antibiotics, and antithrombotics was most strongly associated with the development of an adverse drug event or potential adverse drug event.
CONCLUSIONS - Adverse drug events and potential therapeutic failures are common and frequently severe in patients with AKI exposed to nephrotoxic or renally eliminated medications.
1 Communities
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24 MeSH Terms
Erratum to: effect of patient- and medication-related factors on inpatient medication reconciliation errors.
Salanitro AH, Osborn CY, Schnipper JL, Roumie CL, Labonville S, Johnson DC, Neal E, Cawthon C, Businger A, Dalal AK, Kripalani S
(2012) J Gen Intern Med 27: 1393
MeSH Terms: Humans, Medication Errors, Medication Reconciliation
Added December 10, 2013
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3 MeSH Terms
Direct provider feedback to decrease chemotherapy ordering errors: the "gray envelope" initiative.
Bruce K, Hall L, Castelo S, Evans M, Frangoul H
(2012) Pediatr Blood Cancer 59: 1330-1
MeSH Terms: Antineoplastic Agents, Feedback, Psychological, Humans, Medical Order Entry Systems, Medical Staff, Hospital, Medication Errors, Pharmacy Service, Hospital
Show Abstract · Added March 7, 2014
Chemotherapy errors are the second leading cause of mortality related to medication errors. Most medication errors occur in the provider ordering process. We evaluated the rate of chemotherapy ordering errors in our center and designed an intervention to decrease the rate of ordering errors. The intervention focused on direct confidential written feedback to the providers. Our intervention resulted in a significant decrease in ordering errors from 7% pre-intervention to 3.9% post intervention (P < 0.001). We conclude that direct written provider feedback can result in a significant decrease in chemotherapy ordering errors.
Copyright © 2012 Wiley Periodicals, Inc.
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7 MeSH Terms
Effect of patient- and medication-related factors on inpatient medication reconciliation errors.
Salanitro AH, Osborn CY, Schnipper JL, Roumie CL, Labonville S, Johnson DC, Neal E, Cawthon C, Businger A, Dalal AK, Kripalani S
(2012) J Gen Intern Med 27: 924-32
MeSH Terms: Aged, Cross-Sectional Studies, Female, Health Literacy, Heart Diseases, Hospitalization, Humans, Male, Medication Errors, Medication Reconciliation, Middle Aged, Treatment Outcome
Show Abstract · Added December 10, 2013
BACKGROUND - Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.
OBJECTIVE - To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.
DESIGN, PARTICIPANTS - We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study.
MAIN MEASURES - Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.
KEY RESULTS - On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11).
CONCLUSIONS - Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.
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12 MeSH Terms