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Medication monitoring errors: inappropriate levofloxacin doses
Medication monitoring errors: inappropriate levofloxacin doses
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority.
ECRI (Organization)
Institute for Safe Medication Practices. - Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2009
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Medication Errors
Ofloxacin -- administration & dosage
United States - Genre(s):
- Technical Report
- Abstract:
- Measuring and monitoring a patient's clinical laboratory values is critical for diagnosing problems, gauging effectiveness of treatment, and selecting appropriate doses of many drugs. Breakdowns can occur when necessary monitoring of laboratory values is not ordered or performed or when abnormal levels occur and action is not taken by healthcare practitioners. More than 2,500 event reports submitted to the Pennsylvania Patient Safety Authority were specifically classified as errors involving drug-related clinical monitoring. Analysis reveals that 48% of the events reached the patient. The medication most frequently involved in these reports was levofloxacin (416 events), a drug that requires dosage adjustments based on renal function. Nearly 99% (345) of the 349 reports that included information regarding the node in which the error occurred identified the prescribing node. Almost 92% (382) of the event reports indicated that patients required dose adjustment due to renal function. Of the 416 events involving levofloxacin, 95.4% (397) occurred with patients who were 65 years of age or older, a population with naturally occurring age-related decreases in renal function. The majority (411) of these events was intercepted by practitioners before reaching the patient. Strategies to address these problems include obtaining baseline renal function information, ensuring that current laboratory and testing information is available to all practitioners, interfacing laboratory computer systems with order entry systems, and building computer-based clinical decision support to help guide medication dosing for patients with renal insufficiency.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- NLM Unique ID:
- 101561970 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101561970