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DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Prospective medication order review by a clinical pharmacist is uncommon in many South and Central American countries. Voluntary error reporting and analysis are similarly uncommon. This paper describes the results of pharmacist prospective order review, medication error reporting, and quality improvement activities in a Latin American hospital. METHODS: On January 1, 2020, the hospital initiated prospective review of all medication orders in both the hospital and clinic setting by pharmacists. Health professionals were encouraged to report errors identified to the hospital's voluntary reporting program. Data collected included the medication name and dose, stage of the medication use process, error severity, and error cause. Error reports were periodically reviewed by pharmacy staff. RESULTS: In the 402,100 orders reviewed, errors were found in 605 inpatient orders and 405 clinic orders (0.25%). Most errors were identified before they reached the patient (69.9% of inpatient errors and 81.0% of clinic errors). The prescribing phase was associated with the highest proportion of errors (50.8% of inpatient errors and 41.7% of clinic errors). The most common reasons for prescribing errors were confusing orders and wrong doses. Analgesics (22.7%) and antibiotics (21.3%) were the medication classes most frequently identified. After aggregated review, pharmacists generated 19 clinical alerts leading to system changes and staff education. CONCLUSION: This study demonstrates the impact of prospective order review by pharmacists on patient safety. In addition to preventing errors from reaching the patient, voluntary error reporting and evaluation led to system changes intended to reduce the likelihood that similar errors would occur again.

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BACKGROUND: Although several national organizations have declared the ability to work with electronic health records (EHRs) as a core competency of medical education, EHR education and use among medical students vary widely. Previous studies have reported EHR tasks performed by medical students, but students' self-perceived readiness and comfort with EHRs are relatively unknown. OBJECTIVE: This study aimed to better understand medical students' self-perceived readiness to use EHRs to identify potential curricular gaps and inform future training efforts based on students' perspectives. METHODS: The authors deployed a survey investigating self-perceived comfort with EHRs at 2 institutions in the United States in May 2019. Descriptive statistics were generated regarding demographics, comfort level with various EHR-related tasks, and cross-institutional comparisons. We also assessed the impact of extracurricular EHR experience on comfort level. RESULTS: In total, 147 medical students responded, of which 80 (54.4%) were female, with equal distribution across all 4 years of training. Overall confidence was generally higher for students with longer extracurricular EHR experience, even when adjusted for age, gender, year of training, and institution. Students were most comfortable with tasks related to looking up information in the EHR and felt less comfortable with tasks related to entering new information and managing medications. Fourth-year students at both schools reported similar levels of comfort with EHR use, despite differences in preclinical EHR training. Open-ended comments emphasized the value of experiential training over didactic formats. CONCLUSIONS: Information entry and medication management in the EHR represent areas for future curricular development. Experiential training via extracurricular activities and early clinical exposure may be high-yield approaches to help medical students achieve critical EHR competencies.

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Objective. To determine whether elimination of backward navigation during an examination resulted in changes in examination score or time to complete the examination.Methods. Student performance on six examinations in which backward navigation was eliminated was compared to performance on examinations administered to pharmacy students the previous year when backwards navigation was allowed. The primary comparison of interest was change in student performance on a subset of identical questions included on both examinations. Secondary outcomes included change in total examination score and completion time.Results. No significant reduction in examination scores was observed as a result of eliminating backward navigation. The average time that students spent on a question was significantly reduced on two of the six examinations.Conclusion. Restricting pharmacy students' ability to revisit questions previously answered (elimination of backward navigation) on an examination had no adverse effect on scores or testing time when assessed across three years of the didactic pharmacy curriculum.

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PURPOSE: The role of pharmacist transcription, onsite pharmacist dispensing, use of automated dispensing cabinets (ADCs), nurse-nurse double checks, or barcode-assisted medication administration (BCMA) in reducing medication error rates in critical access hospitals (CAHs) was evaluated. METHODS: Investigators used the practice-based evidence methodology to identify predictors of medication errors in 12 Nebraska CAHs. Detailed information about each medication administered was recorded through direct observation. Errors were identified by comparing the observed medication administered with the physician's order. Chi-square analysis and Fisher's exact test were used to measure differences between groups of medication-dispensing procedures. RESULTS: Nurses observed 6497 medications being administered to 1374 patients. The overall error rate was 1.2%. The transcription error rates for orders transcribed by an onsite pharmacist were slightly lower than for orders transcribed by a telepharmacy service (0.10% and 0.33%, respectively). Fewer dispensing errors occurred when medications were dispensed by an onsite pharmacist versus any other method of medication acquisition (0.10% versus 0.44%, p = 0.0085). The rates of dispensing errors for medications that were retrieved from a single-cell ADC (0.19%), a multicell ADC (0.45%), or a drug closet or general supply (0.77%) did not differ significantly. BCMA was associated with a higher proportion of dispensing and administration errors intercepted before reaching the patient (66.7%) compared with either manual double checks (10%) or no BCMA or double check (30.4%) of the medication before administration (p = 0.0167). CONCLUSION: Onsite pharmacist dispensing and BCMA were associated with fewer medication errors and are important components of a medication safety strategy in CAHs.

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BACKGROUND: Consumer satisfaction is a crucial component of health information technology (HIT) utilization, as high satisfaction is expected to increase HIT utilization among providers and to allow consumers to become full participants in their own healthcare management. OBJECTIVE: The primary objective of this pilot study was to identify consumer perspectives on health information technologies including health information exchange (HIE), e-prescribing (e-Rx), and personal health records (PHRs). METHODS: Eight focus groups were conducted in seven towns and cities across Nebraska in 2013. Each group consisted of 10-12 participants. Discussions were organized topically in the following categories: HIE, e-Rx, and PHR. The qualitative analysis consisted of immersion and crystallization to develop a coding scheme that included both preconceived and emergent themes. Common themes across focus groups were identified and compiled for each discussion category. RESULTS: The study had 67 participants, of which 18 (27 percent) were male. Focus group findings revealed both perceived barriers and benefits to the adoption of HIT. Common HIT concerns expressed across focus groups included privacy and security of medical information, decreases in quality of care, inconsistent provider participation, and the potential cost of implementation. Positive expectations regarding HIT included better accuracy and completeness of information, and improved communication and coordination between healthcare providers. Improvements in patient care were expected as a result of easy physician access to consolidated information across providers as well as the speed of sharing and availability of information in an emergency. In addition, participants were optimistic about patient empowerment and convenient access to and control of personal health data. CONCLUSION: Consumer concerns focused on privacy and security of the health information, as well as the cost of implementing the technologies and the possibility of an unintended negative impact on the quality of care. While negative perceptions present barriers for potential patient acceptance, benefits such as speed and convenience, patient oversight of health data, and safety improvements may counterbalance these concerns.

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BACKGROUND: Health information exchange (HIE) systems are implemented nationwide to integrate health information and facilitate communication among providers. The Nebraska Health Information Initiative is a state-wide HIE launched in 2009. OBJECTIVE: The purpose of this study was to conduct a comprehensive assessment of health care providers' perspectives on a query-based HIE, including barriers to adoption and important functionality for continued utilization. METHODS: We surveyed 5618 Nebraska health care providers in 2013. Reminder letters were sent 30 days after the initial mailing. RESULTS: A total of 615 questionnaires (11%) were completed. Of the 100 current users, 63 (63%) indicated satisfaction with HIE. The most common reasons for adoption among current or previous users of an HIE (N = 198) were improvement in patient care (N = 111, 56%) as well as receiving (N = 95, 48%) and sending information (N = 80, 40%) in the referral network. Cost (N = 233, 38%) and loss of productivity (N = 220, 36%) were indicated as the 'major barriers' to adoption by all respondents. Accessing a comprehensive patient medication list was identified as the most important feature of the HIE (N = 422, 69%). CONCLUSIONS: The cost of HIE access and workflow integration are significant concerns of health care providers. Additional resources to assist practices plan the integration of the HIE into a sustainable workflow may be required before widespread adoption occurs. The clinical information sought by providers must also be readily available for continued utilization. Query-based HIEs must ensure that medication history, laboratory results and other desired clinical information be present, or long-term utilization of the HIE is unlikely.

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OBJECTIVE: The objectives of this cross-sectional study were to estimate the prevalence of unintended discrepancies between three sources of prescription information and to describe the types of electronic prescribing system vulnerabilities identified. METHODS: Staff from community pharmacies identified approximately 200 new prescriptions written at three participating ambulatory care clinics (2 adult, 1 paediatric). Unintended discrepancies were identified by comparing three sources of prescription information: (1) the prescriber's note as documented in the patient's chart; (2) the electronic prescription (e-prescription) entered into the clinic's electronic prescribing software; (3) the medication that was ultimately dispensed by the pharmacy as indicated on the prescription label. The discrepancy rate was calculated by dividing the number of discrepancies identified by the number of prescriptions evaluated. RESULTS: A total of 602 prescriptions written by 33 prescribers were evaluated from the 3 ambulatory care clinics. The discrepancy rate between the prescriber's note and the e-prescription was 1.7%, 0.6% and 3.9% for the three clinics. The discrepancy rate between the e-prescription (clinic) and the prescription label (pharmacy) was 4.2%, 0.9% and 1.5%. Differences between directions for administration was the most common type of discrepancy identified. CONCLUSIONS: Discrepancy rates between the prescriber's note and the e-prescription were similar to the discrepancy rates between the e-prescription and pharmacy label. To reduce outpatient medication errors, a better understanding is needed of the sources of discrepancies that occur within the prescriber's clinic, and those that occur between the clinic and pharmacy.

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PURPOSE: The rates of medication errors across three different medication dispensing and administration systems frequently used in critical access hospitals (CAHs) were analyzed. METHODS: Nine CAHs agreed to participate in this prospective study and were assigned to one of three groups based on similarities in their medication-use processes: (1) less than 10 hours per week of onsite pharmacy support and no bedside barcode system, (2) onsite pharmacy support for 40 hours per week and no bedside barcode system, and (3) onsite pharmacy support for 40 or more hours per week with a bedside barcode system. Errors were characterized by severity, phase of origination, type, and cause. Characteristics of the medication being administered and a number of best practices were collected for each medication pass. Logistic regression was used to identify significant predictors of errors. RESULTS: A total of 3103 medication passes were observed. More medication errors originated in hospitals that had onsite pharmacy support for less than 10 hours per week and no bedside barcode system than in other types of hospitals. A bedside barcode system had the greatest impact on lowering the odds of an error reaching the patient. Wrong dose and omission were common error types. Human factors and communication were the two most frequently identified causes of error for all three systems. CONCLUSION: Medication error rates were lower in CAHs with 40 or more hours per week of onsite pharmacy support with or without a bedside barcode system compared with hospitals with less than 10 hours per week of pharmacy support and no bedside barcode system.

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BACKGROUND: Proton pump inhibitors (PPI) are a widely-used class of drugs for the treatment of gastro-esophageal reflux disease and other acid-related disorders of the gastrointestinal tract. As a class, PPIs have demonstrated a favorable safety profile. However, case reports have suggested that this class of drugs may be linked to acute kidney injury, which may in turn lead to chronic injury or failure. The objective of this study was to determine if an association between PPIs and kidney failure exists and to estimate an effect size for the relationship between PPI use and renal disease. METHODS: A nested case-control study was conducted in a privately insured population in a single Midwestern state including a total of 184,480 patients aged 18 years or older who were continuously enrolled with the insurer for at least 24 months between September 2002 and November 2005. RESULTS: Renal disease was positively associated with PPI use (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.27, 2.32, p < 0.001) even after controlling for potential confounding conditions. After removing patients with potential confounding disease states from the study population, the number of cases (195 of the 854) and controls (607) was lower, but the relationship between renal disease and PPI use remained consistent (OR 2.25, CI 1.09-4.62, p < 0.001). CONCLUSIONS: Patients with a renal disease diagnosis were twice as likely to have used a previous prescription for a PPI. Therefore, it is necessary for physicians to increase recognition of patient complaints or clinical manifestations of this potentially harmful event in order to prevent further injury.

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PURPOSE: Electronic prescribing (e-prescribing) and its accompanying clinical decision support capabilities have been promoted as means for reducing medication errors and improving efficiency. The objectives of this study were to identify the barriers to adoption of e-prescribing among nonparticipating Nebraska pharmacies and to describe how the lack of pharmacy participation impacts the ability of physicians to meet meaningful use criteria. METHODS: We interviewed pharmacists and/or managers from nonparticipating pharmacies to determine barriers to the adoption of e-prescribing. We used open-ended questions and a structured questionnaire to capture participants' responses. FINDINGS: Of the 23 participants, 10 (43%) reported plans to implement e-prescribing sometime in the future but delayed participation due to transaction fees and maintenance costs, as well as lack of demand from customers and prescribers to implement e-prescribing. Nine participants (39%) reported no intention to e-prescribe in the future, citing start-up costs for implementing e-prescribing, transaction fees and maintenance costs, happiness with the current system, and lack of understanding about e-prescribing's benefits and how to implement e-prescribing. CONCLUSIONS: The barriers to e-prescribing identified by both late adopters and those not willing to accept e-prescriptions were similar and were mainly initial costs and transaction fees associated with each new prescription. For some rural pharmacies, not participating in e-prescribing may be a rational business decision. To increase participation, waiving or reimbursing transaction fees, based on demographic or financial characteristics of the pharmacy, may be warranted.

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As expected, bar-code medication administration systems can prevent medication errors. However, health care organizations must be aware of identified failure points in bar coding that may contribute to errors.

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BACKGROUND: Safe and effective prescription writing, using drug formularies, and managing pharmaceutical care are skills medical students need to acquire. Spurred by the Undergraduate Medical Education for the 21st Century (UME-21) grants, the University of Wisconsin and the University of Nebraska independently developed educational workshops to address these competencies. METHODS: The University of Wisconsin's workshop is presented to medical students at the start of their third year. They receive information from pharmacists on medication errors, prescription writing, and drug formularies. A "learners guide" summary is discussed by a physician, which brings into focus the clinical application of the didactic session. A small-group session follows with hands-on experience in writing prescriptions and using formularies for three patient case scenarios. The workshop at the University of Nebraska consists of three sessions during the third-year internal medicine clerkship. In the first session, pharmacists discuss formularies, the Pharmacy and Therapeutics (PT) committee, and the preparation of a drug monograph. During the second session, students develop an evidence-based drug monograph on a product or herbal. In the final session, the class functions as a mock PT committee, and after listening to the drug monographs, determines whether the product should be added to the formulary. We evaluated students' satisfaction with the workshops using Likert scales and assessed students' ability to correctly fill out a prescription form. RESULTS: Both workshops were well received. The mean rating at University of Wisconsin was 1.7 on a scale of 1 (satisfied) to 7 (dissatisfied), and at University of Nebraska it was 3.8 with 5 (outstanding) to 1 (unacceptable). At the University of Wisconsin, on a year-end skills assessment involving 148 students, 100% of the students properly filled out a prescription. Ninety-four percent received an excellent grade, 6% a pass, and no marginal or failing grades were given out. CONCLUSIONS: The workshop on pharmaceutical prescribing was rated favorably by students. After participating in the workshop, students acquired skills in prescription writing.

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