| Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy. | |
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MedLine Citation:
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PMID: 21819031 Owner: NLM Status: In-Process |
Abstract/OtherAbstract:
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BACKGROUND: High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered. METHODS: A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics. RESULTS: Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent. CONCLUSIONS: Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy. |
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Authors:
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Lemuel R Waitman; Ira E Phillips; Allison B McCoy; Ioana Danciu; Robert M Halpenny; Cori L Nelsen; Daniel C Johnson; John M Starmer; Josh F Peterson |
Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Joint Commission journal on quality and patient safety / Joint Commission Resources Volume: 37 ISSN: 1553-7250 ISO Abbreviation: Jt Comm J Qual Patient Saf Publication Date: 2011 Jul |
Date Detail:
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Created Date: 2011-08-08 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 101238023 Medline TA: Jt Comm J Qual Patient Saf Country: United States |
Other Details:
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Languages: eng Pagination: 326-32 Citation Subset: IM |
Affiliation:
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Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA. rwaitman@kumc.edu |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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