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Author Spotlight: An Efficient Methodology to Confidently Differentiate and Characterize Fentanyl Analogs
Published on: November 8, 2024
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Pictorial prescribing reduces fentanyl drug administration errors: a simulated controlled study
Stephen W Booth1, Maria Gloag2, Sara Kinna2
1Division of Anaesthesia, University of Cambridge, Cambridge, UK.
BMJ Supportive & Palliative Care
|July 17, 2015
Summary
Pictorial prescribing significantly reduced medication errors in choosing fentanyl preparations among nurses. This strategy improves understanding and may prevent errors with non-interchangeable drug products.
Area of Science:
- Pharmacology
- Patient Safety
- Medical Education
Background:
- Transmucosal fentanyl formulations (intranasal, sublingual, buccal, lozenges) are used for cancer pain but are not interchangeable.
- Variations in transmucosal fentanyl products can lead to medication errors.
Purpose of the Study:
- To compare medication errors using handwritten drug charts versus pictorial self-adhesive labels for fentanyl prescriptions.
- To assess the impact of pictorial labels on nurses' understanding of fentanyl preparation and dosing.
Main Methods:
- 54 nurses evaluated simulated handwritten and pictorial prescription charts.
- Nurses identified intended fentanyl preparations and doses from available product options.
- Medication errors and prescription clarity were measured using Likert scales.
Main Results:
- Pictorial labels significantly reduced errors in selecting the correct fentanyl preparation (20 vs. 6 errors).
- No significant difference was found in dose errors between the two chart types.
- Pictorial labels substantially improved nurses' understanding of preparation, dose, and maximum dosing intervals.
Conclusions:
- Pictorial prescribing is a promising strategy to decrease medication errors related to fentanyl preparation selection.
- The use of pictorial prescribing may be beneficial for other drugs with non-interchangeable formulations.
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