Use of Contraindicated Antiplatelet Medications in the Setting of Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

BACKGROUND: Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described. METHODS AND RESULTS: Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts. Adjusted association between contraindicated medication use and outcomes of periprocedural bleeding and 30-day mortality were assessed using Cox proportional hazards with inverse probability weighting. Among 64 294 patients undergoing PCI, 11 315(17.6%) had a contraindication to a common antiplatelet medication and 737 (6.5%) of these patients received a contraindicated medication. In unadjusted analyses, any contraindicated medication use was associated with both increased bleeding and 30-day mortality. In adjusted models, contraindicated abciximab use in patients with thrombocytopenia (hazard ratio, 2.23; 95% confidence interval, 1.58-3.16) and in patients with a previous stroke (hazard ratio, 1.93; 95% confidence interval, 1.37-2.71) remained significantly associated with increased bleeding. Contraindicated abciximab use was not significantly associated with 30-day mortality in adjusted models. Use of eptifibatide in dialysis patients was not significantly associated with an increased risk of bleeding or mortality. CONCLUSIONS: In this national cohort, ≈18% of patients undergoing PCI had contraindications to common antiplatelet medications. Approximately 6% of those patients received a contraindicated medication with attendant bleeding risk, although this did not translate into significantly higher risk of 30-day mortality. Continued efforts to reduce contraindicated medication use may help avoid periprocedural complications.

Injury and death associated with incidents reported to the patient safety net.

The authors retrospectively evaluated anonymously submitted inpatient medical error reports from 8 institutions participating in the University HealthSystem Consortium Patient Safety Net (PSN) in 2004 in an attempt to focus patient safety efforts on problems that were most commonly associated with harm. Of the 25,300 incidents reported, 3381 (13.3%) were associated with adverse events (AEs), and 109 (0.4%) were associated with death. Although the most commonly reported categories of incidents associated with AEs were complications of procedure/treatment/test (29%), falls (17%), and medication errors (10%), the taxonomy of the PSN limited efforts to find specific errors in care that might be addressed by attempts to improve patient safety. Skin breakdown and falls were confirmed as presenting substantial risks to hospitalized patients, in that 59% of the incidents reported in the skin integrity category and 22% of falls resulted in AEs. The benefits and limitations of a voluntary reporting system are discussed.

Supporting staff recovery and reintegration after a critical incident resulting in infant death.

A critical incident is described as any sudden unexpected event that has the power to overwhelm the usual effective coping skills of an individual or a group and can cause significant psychological distress in usually healthy persons. A Just Culture model to deal with critical incidents is an approach that seeks to identify and balance system events and personal accountability. This article reports a critical incident that occurred at the Neonatal Intensive Care Unit, Methodist Hospital of Indianapolis, when 5 infants received an overdose of heparin that resulted in the death of 3 infants. Although care of the family after the critical incident was the immediate priority, the focus of this article was on the recovery and reintegration of the NICU staff after a critical incident based on the Just Culture philosophy.

[Medication errors in hospitalised patients]. / Feilmedisinering hos pasienter innlagt i sykehus.

BACKGROUND: Medication errors can arise both during prescription and administration (dispensing and distribution) of drugs. Little is known about types of medication errors in Norwegian hospitals. MATERIAL AND METHOD: All medication errors reported at St. Olav's Hospital from 1 July 2002 to 30 June 2006 were reviewed and analysed. RESULTS: 610 reports were identified. The most common cause of reporting (39 %) was prescription of a different dose from the one prescribed. Other frequent causes were administration of a different drug than the one prescribed (17 %), inadvertent subcutaneous infusion of an intravenous drug (15 %), and that the drug was given to another patient (12 %). The errors were almost exclusively reported by nurses. In 107 cases (18 %), precautions had been taken to reduce the extent of injury after the error had been identified. The causes of errors could be classified in three main categories: Nonvigilance caused by stress, lack of appropriate routines or violation of them, and lack of appropriate skills/negligence. INTERPRETATION: Changes of routines, improved education in existing routines, and increased pharmacological competence may contribute to prevention of medication errors.

Enhancing safety with potassium phosphates injection.

The inadvertent administration of concentrated potassium chloride resulting in patient death is well-documented in Canada and other countries. Vials of potassium phosphates contain more than twice the concentration of potassium compared to vials of potassium chloride concentrate. If inadequately diluted or administered too rapidly, intravenous potassium phosphate can also lead to serious patient harm. This article contains information reprinted with permission from an ISMP Canada Safety Bulletin (ISMP Canada, 2006, April 25) for the purpose of enhancing safety with potassium phosphates injection.

Using performance improvement strategies to reduce and prevent medication errors. 1.

The headlines feature tragic stories describing errors in medical practice. Medical literature reveals that errors in medical practice are common. In 1999, the Institute of Medicine released its report. "To Err is Human," that detailed an estimated 44,000 to 98,000 deaths annually due to medical errors. In September of 2002, the Archives of Internal Medicine released a study of medication errors observed in 36 healthcare facilities. Medication errors were commonly occurring in 19% or nearly one error out of every five doses administered in a typical hospital. It is imperative to analyze patient safety issues related to medication administration. This paper presents methods to improve the quality of care delivered by: Building effective structures through efficient use of technology. Establishing improved process through collaboration and teamwork. Measuring and reporting performance outcomes.

Indicators of preventable drug-related morbidity in older adults 2. Use within a managed care organization.

OBJECTIVE: To determine the incidence of preventable drug-related morbidity (PDRM) in older adults in a provider-sponsored network and identify risk factors for PDRM. METHODS: The study was based on a retrospective review of an integrated health care database, using 52 newly developed clinical indicators of PDRM. The incidence of PDRM was determined by identifying individuals in the database who matched an outcome and pattern of care associated with an indicator. Risk factors were determined through a forward inclusion logistic regression model. The subjects in this study were 3,365 older adults enrolled in a hospital-based health care system in Florida in 1997. The principal outcome measure was identification of individuals who matched a PDRM indicator and risk factors for PDRM. RESULTS: Ninety-seven enrollees who matched one or more of 52 PDRM indicators were found in 3,365 older adults, for an overall incidence rate of 28.8 per 1000. The top 5 indicators of PDRM were responsible for 46.8% of all PDRMs found. Regression analysis identified 5 risk factors: 4 or more recorded diagnoses, 4 or more prescribers, 6 or more prescription medications, antihypertensive drug use, and male gender. CONCLUSION: This study demonstrated that clinical indicators can be used in a managed care organization to identify seniors who have experienced a PDRM. The risk model should better prepare managed care organizations to proactively identify patients at risk for PDRM and to optimize medication use in older adults.

Reporting medication errors through computerized medication administration.

The incidence of medication errors has risen dramatically during the last decade to an alarming number. Nurses report only 5% of significant errors, those considered life threatening. Little research has been done related to medication errors at the administration stage or reporting methods. The purpose of this study was to compare medication error rate per 1,000 doses administered before and after the implementation of a bar code medication administration system. The study was conducted on two medical-surgical units at a midwest government hospital 12 months both before and after the implementation of the Bar Code Medication Administration system. The medication error rate per 1,000 doses administered by a nurse after implementation of the Bar Code Medication Administration system showed an 18% increase. The results probably do not indicate an increase in medication errors but rather an increase in the number of medication errors reported. This research highlights problems with programs evaluating medication errors and new technology implementation. Evaluators must have accurate baseline data before implementation. Past research has shown that the medication error rate has been underreported. In contrast to a staff reporting system, the computerization of medication administration improves the reporting system by reporting all errors. Once a more accurate error rate is known, new technology can be created, evaluated, and refined to reduce medication errors.

Methods to assess the economic outcomes of clinical pharmacy services.

Studies that demonstrate the clinical and economic burden of drug misadventures have been published. The economic burden of drug misadventures likely exceeds $100 billion annually in the United States alone. Clinical pharmacy services (CPS) have been shown to reduce negative clinical outcomes and costs of drug therapy. Pharmacy practitioners and pharmacy managers need to demonstrate the impact of CPS at the local level and present the value to financial decision-makers to gain support for implementation, continuation, and/or expansion of those services. The basic model of an economic evaluation includes measurement of both costs and consequences of a service and of an alternative for comparison. Strategies for economic assessments include the generalization from previously published literature, use of modeling techniques, and measurement of actual costs and consequences of an existing service. Guidelines for conducting an economic assessment are widely available. Pharmacy practitioners and managers should use these methods of assessing economic outcomes of CPS and, at the same time, develop relationships and skills to effectively communicate the value of those services so as to ensure long-term success.