Improving Medication Safety in Community Pharmacy

Define medication errors

Any preventable event that has the potential to lead to inappropriate medication use or patient harm during prescribing, transcribing, dispensing, administering, adherence, or monitoring a drug

Discuss the extent of medication errors and their impact on patient care: What is a medication error that stopped before harming the pt?

“Near misses” or “a potential adverse drug event:”

Discuss the extent of medication errors and their impact on patient care: What is the medication use process?

1. Selection + Procuring

2. Prescribing

3. Dispensing

4. Administering

5. Monitoring

Discuss the extent of medication errors and their impact on patient care: How often, and what is the extent of medication errors in the US?

• Medications harm at least 1.5 million people per year

• Pt deaths: 198,000 in 1995 to 218,000 in 2000

• Cost: $177 billion per year

Discuss the factors that contribute to medication errors: What are the key elements in medication safety?

1. Patient Information

2. Drug Information

3. Communication of drug orders and other drug information

4. Drug labeling, packaging, and nomenclature

5. Drug standardization, storage and distribution

6. Medication device acquisition, use and monitoring

7. Environmental factors, workflow and staffing patterns

8. Staff competency and education

9. Patient education

10. Quality processes and risk management

Discuss the factors that contribute to medication errors: Discuss what patient information is typically provided and where there could be an error

• Basic demographic and clinical information

• serious, ADEs stem from insufficient information about pt’s before prescribing, dispensing, and administering

• Correctly dispensed prescription handed to a patient for whom it was not intended is an error - avoid by consistent use of a second patient identifier

Discuss the factors that contribute to medication errors: Discuss where there could be an error with drug information

• preventable adverse drug events (ADEs) are directly related to inadequate dissemination of drug information

• Overall lack of knowledge about drug therapy was the most common cause of medication errors during both drug prescribing and drug administration, with dosing errors occurring most frequently

• miscalculations or incorrect expression of measurement or drug concentration

• Wrong dose and wrong drug choice

Discuss the factors that contribute to medication errors: Discuss where there could be an error with communication of drug orders and other drug information

• Methods of communicating prescription orders and other drug information are standardized and automated to minimize the risk for error

• use of incorrect drug names, confusing expressions of dosage forms, decimal places, and misunderstood abbreviations

• Illegible and legible handwriting

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Drug labeling, packaging, and nomenclature

• drug products that have similar or confusing manufacturer labeling/packaging and/or drug names that look and/or sound alike

• ensure prescription labels clearly identify the patient, product, directions for use, the dispensing pharmacy, and any other important information that the patient may need to take the medication accurately and safely

• Tall man (mixed case) letters call attention to a drug's name and help with look-alike/sound-alike drugs

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Drug standardization, storage and distribution

• Never allow food or drink in any refrigerator used to store medications

• Need to review stock for short-dated products that need to be removed from inventory

• Need to store expired, returned or recall medications in an area away from regular stock

• Avoid cluttered shelves

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Medication device acquisition, use and monitoring

• Appropriate safety assessment of drug delivery devices prior to their purchase and during their use is key to safe medication administration

• Competency in using drug delivery devices

• new devices come to the market, it is essential that training tools for proper use and potential hazards be available to train healthcare providers and patients

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Environmental factors, workflow and staffing patterns

• poor lighting, cluttered work-spaces, noise, interruptions,

  and non-stop pharmacy activity

• process of transcribing orders and order entry, as pharmacy staff are frequently answering telephones

  and requests for information while carrying out these responsibilities

• Reduced staff levels and increased workload

• Poorly designed systems, processes and workflow

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Staff competency and education

• New medications being used in the pharmacy

• High-alert medications which have the greatest potential to cause patient

• harm if an error occurs, or drugs with unusual or critical dosing considerations

• Protocols, policies and procedures related to medication use, including those related to the use of drug delivery/administration devices

• Medication errors that have occurred within the organization or occurred in other organizations, and the error prevention strategies

Discuss the factors that contribute to medication errors: Discuss where there could be an error with Patient education

• the final link in the medication-use process

• ongoing education by physicians, pharmacists and nurses about drug brand and generic names, indications, usual and actual doses, expected and possible adverse effects, drug or food interactions and how to protect themselves from errors

Examine approaches to minimize the risk of medication errors

Traditional efforts at error reduction have focused on individual practitioners (training, exhortation, rules and disciplinary action to improve performance)

• Human factors specialists and error experts reject this approach - more effective to change the system as a whole than to target individuals for improvement

• redesign the systems and processes that lead to errors rather than focus efforts on correcting the individuals who make errors