
Editorial
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These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs.
Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.
Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site (www.ismp.org), by calling 800-FAIL-SAFE, or via e-mail at
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA's) MedWatch program (800-FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with our readers.
The complexity of cancer chemotherapy requires that pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparing, dispensing, and administering antineoplastic therapy and to the agents, commercially available and investigational, used to treat malignant diseases.
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There has been an increase in therapeutic interchange (TI) practices in institutional settings because of the growing number of “me too” drugs and the desire for hospitals to minimize their formularies' economic impact. The Texas Medical Center (TMC) Clinical Pharmacists Task Force conducted a study to determine TI practices at TMC member institutions.
The task force members who represented a hospital were polled to determine whether their institution participated in a TI process for medication dispensing. Members who provided a positive response were asked to submit a copy of the institution's policy and/or procedure for review. Each policy and procedure was reviewed to determine the therapeutic classes of agents involved in TI, as well as the preferred agents.
Of the hospitals involved in the study, 6 reported the presence of policies/procedures for TI practices, and it was found that 3 policies/procedures were common. There were 5 common therapeutic classes of agents involved in TI at all 6 hospitals. Most endorsed the use of cefoxitin or cefepime as the preferred antimicrobial agent. Famotidine was the preferred H2 antagonist, and pantoprazole was the recommended proton pump inhibitor. Simvastatin was the approved alternative for beta-hydroxybeta-methylglutaryl-coenzyme A (HMG CoA) reductase inhibitors, and for all requested angiotensin-converting enzyme inhibitors, lisinopril was the recommended formulary agent.
Although this project identified some consistency in TI practices, it also recognized inconsistencies in the conversions used for select interchanges; these should be further researched.
In 2006 the Institute of Medicine reported that at least 400,000 preventable adverse drug events (ADEs) occur annually among patients being hospitalized, with costs of $3.5 billion (or $8,750 per preventable ADE). Recommended medication error prevention technologies include computerized prescriber order entry, bar-code medication administration, and computerized intravenous (IV) safety systems with dose-error reduction software. When St. Joseph's/Candler Health System replaced its existing IV pumps, the decision to incur the incremental cost for “smart” IV safety systems rather than traditional IV pumps resulted in financial benefits, improved safety, improved quality of care, and increased nursing satisfaction.
Electronic data recorded at the bedside as caregivers administered medications provided information from which actual cost avoidance could be more readily calculated and presented objective evidence of the fiscal value of investments in innovative technologies.
Over a 5-year period, implementation of these smart systems reduced high-risk medication errors and patient-controlled analgesia-related undesired outcomes, helped avert at least 471 preventable ADEs, and provided a 5-year return on investment (ROI) of $1.87 million, with an internal rate of return of 81%.
Financial analysis of the incremental costs of IV safety systems can help calculate anticipated ROI accurately and better prioritize implementation of these systems.
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Change is not a new phenomenon in the health care industry, and reactions to change are determined by many things—personal experiences and professional responsibilities to name a few. Gradual transformation in the way health care information is managed is now being met with an opportunity for swift and significant change with regard to how this information is aggregated and used. This article addresses these opportunities for change from an enterprise perspective.