Delayed Administration and Contraindicated Drugs Place Hospitalized Parkinson's Disease Patients at Risk; Doxorubicin Liposomal Mix-up; Avoid Mix-ups between Hydroxyprogesterone and Medroxyprogesterone

Abstract

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 ismpinfo@ismp.org. ISMP guarantees the confidentiality and security of the information received and respects reporters' wishes as to the level of detail included in publications.

Purposeful collaboration: Enriching lives for people with Parkinson’s disease

“…The practice changes that occurred in response to this project became core business and were incorporated into a clinical guideline for the care and management of patients with PD at presentation and admission to hospital, with the aim of maintaining meaningful long-term sustained change with improved outcomes (Aminoff et al, 2011;Gerlach et al, 2011;Harris & Fry, 2017). These results are promising and reflect the recommendations and conclusions of other research relating to the care and management of patients admitted to hospital with PD (Aminoff et al, 2011;Chenoweth, Sheriff, McAnally, & Tait, 2013;Chou et al, 2011;Cohen & Smetzer, 2015;Donizak & McCabe, 2017).…”

“…The insidious onset, no known cure, and progressive nature of PD mean it is challenging to treat and requires a multidisciplinary approach (Bramble, Carroll, & Rossiter, 2018). In the inpatient context, a lack of specialist knowledge and low adherence to PD medication regimens can result in poor clinical outcomes such as extended recovery time, worsening symptoms, falls and morbidity (Cohen & Smetzer, 2015;Donizak & McCabe, 2017;Grissinger, 2018). These adverse events can result in longer hospital stay, representations and re-admissions, and increased health system costs (Donizak & McCabe, 2017;Harris & Fry, 2017).…”

Editorial: Hospitalization and Parkinson's disease: safety, quality and outcomes

“…For over a decade, the Parkinson's Foundation has worked diligently to shed light on hospital safety gaps and encourage the development of solutions. Significant gains were made through an initiative led by Michael Okun through collaboration among the Parkinson's Foundation Global Care Network resulting in publications of dozens of articles identifying the risks to PWP (Magdalinou et al, 2007 ; Buetow et al, 2010 ; Derry et al, 2010 ; Wood et al, 2010 ; Aminoff et al, 2011 ; Chou et al, 2011 ; Delea et al, 2011 ; Gerlach et al, 2011 , 2013 ; Hou et al, 2012 ; Wawruch et al, 2012 ; Anderson and Fagerlund, 2013 ; Fagerlund et al, 2013 ; Hassan et al, 2013 ; Ahlskog, 2014 ; Cohen and Smetzer, 2015 ; Crispo et al, 2016 ; Shahgholi et al, 2017 ). Their research also led to the creation of the Parkinson's Foundation hospital safety kits, which have been distributed to over 150,000 PWP.…”

Antiparkinsonian Medication Reconciliation as a Strategy to Improve Safety by Preventing Medication Errors

“…according to a patient's unique schedule, to avoid periods of suboptimal treatment 6 that will, ultimately, lead to an immediate augmentation of symptoms. 7 In this sense, developing strategies focused on promoting accurate PD medication administration is crucial, even more throughout hospitalization, a critical period for PD patients when viewed from the perspective of pharmacological treatment, 7 especially considering that PD patients are admitted to hospitals more frequently and longer than the general population. 8,9 Onethird of all patients with PD visit an emergency department or hospital each year, 10 yet about 70% of neurologists report that PD patients do not get their medication properly when hospitalized.…”

“…Moreover, the administration of PD medication also needs to be carried out at a particular time to avoid missing doses or inaccurate dosage schemes that may result in motor and non‐motor consequences 5 . Therefore, medications should be administered on time, according to a patient's unique schedule, to avoid periods of sub‐optimal treatment 6 that will, ultimately, lead to an immediate augmentation of symptoms 7 …”