The Institute for Safe Medication Practices is an American 501(c)(3) organization focusing on the prevention of medication errors and promoting safe medication practices. It is affiliated with the ECRI Institute.
OBJECTIVE To collect medication error (ME) data during the perianesthetic period from small animal clinics. SAMPLE 6 small animal general practice veterinary clinics. METHODS Small animal general practice veterinary clinics were recruited in this prospective observational study, with staff given a presentation on medical errors and instructed on how to submit medication error reports to an online reporting system. Errors were classified according to type and timing. RESULTS A total of 2,728 general anesthesia or sedation procedures were performed, with 49 ME reports submitted. One duplicated report of the same error was excluded, resulting in a ME rate of 1.8%. Most reports (69% [33/48]) were near misses. The remaining 31% were MEs that reached the patient but did not cause harm. Wrong dose errors were the most common type (63% [30/48]), of which 80% (24/30) were calculation errors. Premedication/sedation and maintenance were the most reported stages, at 47% (20/43) and 23% (10/43), respectively. None of the MEs reported resulted in an adverse event, with an approximately 2:1 ratio of near-miss to no-harm MEs. The observed patterns of MEs reported, including type and timing, represent a target for further education. CLINICAL RELEVANCE These results quantify the ME rate in general practice veterinary clinics, providing an initial benchmark for MEs during the perianesthetic period.
BACKGROUND:Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group.METHODS:The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge.DISCUSSION:If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely.TRIAL REGISTRATION NUMBER:ClinicalTrials.gov identifier: NCT04077281.
Ann Shastay, MSN, RN, AOCN, is Senior Manager, Publications, Institute for Safe Medication Practices, Plymouth Meeting, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices (ISMP), 5200 Butler Pike, Plymouth Meeting, PA 19462.
Ann Shastay, MSN, RN, AOCN, is the Senior Manager, Publications, Institute for Safe Medication Practices, Plymouth Meeting, Pennsylvania. The author declares no conflicts of interest. Address for correspondence: Ann Shastay, MSN, RN, AOCN, Institute for Safe Medication Practices (ISMP), 5200 Butler Pike, Plymouth Meeting, PA 19462.
( Can J Anesth/J Can Anesth. (2023) 70:811–816) This editorial refers to a recent case published by Dr Pysyk and Dr Filteau describing an inadvertent administration of tranexamic acid into the epidural space. The authors of the editorial discuss this case involving a medication error and propose mechanisms to prevent similar errors in the future. While the error was recognized and managed without immediate adverse effects, the potential for catastrophic consequences was highlighted.
