Ways To Avoid Medication Mix-Ups Highlighted In New Patient Safety Report

Health experts have released a new report that outlines ways that technology could be used to improve patient safety and mitigate the risks associated with medication errors and mix-ups, which have been found to cause more than 2 million adverse health consequences over the last several decades. 

Experts from the Emergency Care Research Institute released a new report this month,  Health IT Safe Practices for Closing the Loop , aimed at addressing safety issues related to tracking diagnostic test results and medication changes that can be easily missed.

The Partnership for Health IT Patient Safety, a multi-stakeholder collaborative in which the Institute for Safe Medication Practices (ISMP) is a participant, have published research indicating how frequent mix-ups in medication and miscommunication can result in misdiagnosis, delayed treatment or the accidental prescribing of medication.

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The groups performed an evidence based literature review of more than 2 million related adverse reports and put together a methodical analysis to provide a toolkit that could be used on a daily basis in the healthcare system worldwide.

The toolkit provides ways to make the healthcare system’s IT safer by addressing safety issues related to tracking diagnostic test results and medication changes. The workgroup identified ways to implement strategies based on developing and applying IT solutions to communicate the right information, including data needed for interpretation to the right people, at the right time, in the right format.

“The problem of not closing the loop has a significant impact on patients and care givers, and can lead to devastating effects on the outcome of patients,” Dr. Christoph U. Lehmann of Vanderbilt University, a member of the advisory panel, said in a press release.

The report outlines scenarios in which IT solutions could have prevented misdiagnosis and delayed treatment. One scenario involved a patient who underwent an ultrasound for testicular pain from possible testicular torsion. The scan showed no testicular torsion, however it did note a “suspicious mass” that was overlooked, despite the doctor and nurse practitioner signing off on the report. Roughly seven months later the patient returned with complaints of pain and a large testicular mass was found that could have been treated seven months prior.

Additional scenarios presented by the groups included medication prescribing errors, including one report of a woman whose doctor noticed her potassium levels were increased and discontinued prescribing her potassium medication. Despite the doctor discontinuing the medication in the electronic health record (EHR), there was no mechanism to inform the pharmacy not to refill the prescription. The woman’s prescription was refilled and she received phone calls to pick it up after the doctor ordered its discontinuation.

The intent of the toolkit is to make the medical field safer by implementing technological safeguards that help mitigate missed, delayed, and incorrect diagnoses on diagnostic testing results and medication changes. This most recent publishing is the fourth in a series of safe practices toolkits published by the private-sector partnership since 2014.


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