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MEDICATION ERRORS AND PHARMACY
SHABIR M. SOMANI
Director of Pharmacy
University of Washington Academic
Medical Center
Associate Professor and Vice Chair
University of Washington School of Pharmacy
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Medication Use Process
• Complex system
• Opportunities for error
• Impacts patient care
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Defensive Layers in the Medication System
Prescriber
Pharmacist
Nurse
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Latent Medication System Errors
Latent Errors• handwriting• incomplete
information• MAR transcription• unclear labeling• high workload• etc
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Latent Error and the Preventable ADE
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MedicationErrors
ADRsADEs
Adapted from Bates et al.
Relationships Among Medication Misadventures
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Framework for Identifying Errors
Patient Receives
Treatment
No ErrorMade
Good Outcomes
Bad outcomes (Unpreventable ADE due to underlying disease)
Error Made
Minor
Serious
Caught Close Call
Not Caught Minor or no injury(Preventable ADE)
Caught Close Call
NotCaught
Patient Injury(Preventable ADE)
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Causes of Medication Errors
• Nature of drugs• Gaps in biomedical knowledge• Difficulties in training• Time constraints and interruptions• Incomplete access to patient specific data
Hennessy, E. AJHP 2000; 57:543-548
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Causes of Medication Errors
• Ambiguities in Professional Practice roles• Reliance on error prone processes• Pervasiveness of commercial influence• Economic barriers• Multiple and changing formularies• Patient non-adherence to therapy
Hennessy, E. AJHP 2000; 57:543-548
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Cost of Adverse Drug Events
• Diversion from therapeutic objective
• Negative outcome from event
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Cost Impact of ADE’s
Increased Increased
LOS Cost
ADE 2.2 $3,244
Preventable ADE 4.6 $5,857
Bates DW, et al. The Costs of Adverse Drug Events in Hospitalized Patients. JAMA. 1997; 277:307-311
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Unfortunately the way we often calibrate our medication system
is with
Sentinel Events
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Airline Safety
• Redundancy built into system• Interface between equipment and people• “But my luggage!!”
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Order Written (56%)
Interpreted by PharmacistInterpreted by Nurse
Prepared and dispensed (4%)Transcribed to MAR (6%)
Administered to patient (34%)
Bates Data in Red
Preventable ADE’s
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Pharmacy
A key in medication safety
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BUILD
Patient centered systems
NOT
Department centered
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Take responsibility for the
Medication Use system
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IOM Report on Medical Errors
• Create the Center for Patient Safety
• Required reporting of serious mistakes to state agency
• Encourage voluntary reporting
• Extend peer-review protection to safety data used for quality improvement
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IOM Report on Medical Errors
• Focus performance standards on patient safety
• FDA to focus on safe use of drugs
• Continually improved patient-safety as a goal
• Implement proven medication safety systems
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IOM Report and Pharmacy
“Implement proven medication safety systems”
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Murray, M. AJHP 2000;57:565-571
Patient Information systems
• Physician order entry • Pharmacy computer system• Automated dispensing system• Point of care system
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Interruptions
• Pay attention to Physical environment
• Minimize interruptions– Order Entry– checking
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Staff Training
• Orientation
• Training
• Evaluation of Competency
• Continuous Learning
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Patient Education
• Educate patients on medications
• Empower patients
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Pharmacist Instant Action Items
• Question unclear & unusual orders
• Focus on high-alert drug issues
• Reduce interruptions and distractions
• Read labels three times
• Report errors
• Eliminate the culture of blame
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Process Improvement
• Continuous Quality Improvement
• Data driven
• System focused
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Ideal System
• Electronic order entry• Pharmacy system with checks• Single dose dispensing• Bar-codes• Point of care system• Patient involvement