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Preventing Medication Errors
intake and output, electrolytes, and pain (Bulechek et al., 1994). In intensive care units, monitoring is more frequent, more often invasive, and technologically complex (IOM, 2004b). In long-term and home care, other patient characteristics are observed and evaluated to determine the response to medications, including cognition, communication, vision, mood and behavior patterns, psychosocial well-being, and ability to perform daily care activities (e.g., grooming, bathing). Results of patient monitoring and any adverse effects are documented in the patient’s medical record. For nursing homes and home health services, these assessments must be completed by licensed nurses according to federally prescribed guidelines to comply with federal regulatory and reimbursement requirements (i.e., Medicare) (ANA, 1998; IOM, 2004b).
Medical devices designed for patient monitoring range from small, wearable devices that monitor a single physiological parameter, such as blood pressure, to complex devices (e.g., respiratory oximeters, electrocardiograms) that measure a variety of parameters and transmit them electronically to a central monitoring station. Changes in physiological responses detected with these devices can signal a nurse that the patient may be experiencing an adverse drug reaction. For example, a heart monitor may detect an inappropriate change in heart rate or rhythm after administration of a cardiac drug. Medication infusion devices, such as smart pumps and patient-controlled analgesia machines, go a step further and maintain a record not only of medications administered, but also of errors that may have occurred. In addition, telemedicine and remote patient monitoring devices that are connected to specialized computer modems and can reliably measure and transmit physiological data (e.g., blood pressure, heart rate, blood glucose level) are a growing method of care management supporting providers and patients in rural settings (inpatient, ambulatory, home/self-care) (Field and Grigsby, 2002).
The ability of pharmacists to monitor the effectiveness of drug therapy through computerized pharmacy and laboratory database systems has been an important advance in assessing patient responses to medications, especially in inpatient settings (Knowlton and Penna, 2003). Linkage of these systems enhances opportunities for improved monitoring through evaluation and review of drug appropriateness, drug dosages, drug–drug interactions, drug–allergy conflicts, drug blood serum concentrations, and metabolic responses, particularly for potent medications with narrow therapeutic indices (Armstrong, 2000; Knowlton and Penna, 2003; Schiff et al., 2003). Electronic medical records with event-driven surveillance systems are able to monitor patients around the clock and have been shown to detect some adverse drug events early enough to prevent their progression from mild or moderate to severe (Classen et al., 1991; Evans et al., 1991, 1994; Jha et al., 1998; Bates and Gawande, 2003). These systems monitor specific signals