Presentation on medication errors in clinicalpharmacy.ppt
- 1. Medication Errors • A medication error is an episode associated with the use of a medicine that should be preventable through effective control systems. • Pharmacists have had a long-standing interest in improving medication safety and have studied ways to reduce medication errors. • The definition used in medication error studies conducted by pharmacists was a more restricted one of error. • In these studies, a medication error was defined as any deviation from the prescriber’s order. • This definition does not consider the clinical outcome of the error.
- 2. • The American Society of Health- System Pharmacists’ (ASHP) definition of medication errors includes prescribing, dispensing, medication administration and patient compliance errors. • They define the following categories of medication errors: • Prescribing errors • Omission errors • Wrong time errors • Unauthorised drug errors • Improper dose errors (administration of a dose that is greater or less than the amount prescribed) • Wrong dosage form errors (administration of a drug product in a different dosage form from that prescribed) • Wrong drug preparation errors (drug product incorrectly formulated or manipulated before administration)
- 3. • Wrong administration or technique errors (inappropriate procedure or improper technique in the administration of the drug) • Deteriorated drug errors (administration of a drug that has expired or whose physical or chemical dosage form integrity has been compromised • Monitoring errors (failure to review a prescribed regimen for appropriateness or failure to assess response to prescribed therapy) • Compliance errors (failure of the patient to adhere to the prescribed medication regimen) Other medication errors (any error that does not fall into one of the above categories)
- 4. • The National Coordinating Committee on Medication Error Reporting and Prevention (NCCMERP) in the United States is an interdisciplinary healthcare group consisting of representatives of fourteen healthcare organizations. • Their purpose is to promote the reporting, understanding and prevention of medication errors and focus on ways to protect patient safety through the coordinated efforts of associations and agencies. • NCCMERP defines medication errors as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medicine is in the control of the healthcare professional, patient or consumer.
- 5. • Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing; order communication; product labelling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. • It has been shown that only a small percentage of medication errors actually result in harm to the patient. • The current definition of medication error focuses on breaks in performing any step in the medication use system, not just the drug administration step. • As previously noted, the incidence of medication errors in most hospitals is approximately 10%.
- 6. Adverse Drug Events • The term adverse drug event (ADE) is a newer term that emerged as studies of the epidemiology of adverse medical events were published. • The Harvard Medical Practice Study identified medications as the most common cause of injury resulting from medical care. • This represented a shift in focus to the preventable adverse outcomes associated with drug therapy, and errors as one cause of these adverse outcomes. • Bates et al. defined an ADE as an injury resulting from medical interventions related to a medicine. • They noted that most ADEs are dosedependant and potentially predictable and constitute the greatest percentage of errors that result in clinical harm.
- 7. • They also noted that a smaller number of ADEs are unpredictable, idiosyncratic or allergic reactions to medicines (note that this resembles a category of events that could be defined as adverse drug reactions). • These authors introduced another term, ‘potential ADE’, which is defined as a medication error with the potential for injury, but in which no injury occurs (note the relationship between medication errors and ADEs). • ADEs may therefore result from medication errors or from adverse drug reactions in which there was no error. • The relationship between medication errors, adverse drug events and potential adverse drug events is shown in Fig. 28.1.
- 9. • The terms adverse drug event and adverse drug reaction (ADR) may be confused. • Anadverse drug reactionis a ‘response to a drug which is noxious and unintended and which occurs at doses normally used in humans for prophylaxis, diagnosis or therapy of disease or for the modification of physiologic function’. • In other words, an ADR is harm directly caused by the drug at normal doses, during normal use. • An example of an ADR is nausea resulting from chemotherapy. • A death associated with a prescribed overdose of chemotherapy that was not detected and corrected before a fatal dose was administered to a patient is an ADE.
- 10. Epidemiology of Medication-related Problems • Almost every patient receiving healthcare receives medicines as part of their care. • Literally, millions of doses per year are administered to patients in the average hospital, and billions of doses are self- administered in the outpatient setting. • How often do medication-related problems actually occur? What is the cause of such problems? How much unnecessary cost results from adverse drug events, particularly those that are preventable? • Most medication error studies have been based on an observation- based methodology where a statistically valid number of drug administration events were observed and the activity compared to the prescriber’s order.
- 11. • Because wrong administration time errors are common, and often do not result in an adverse event, some studies exclude them in the reported error rate.
- 12. • The lowest medication error rate ever reported (0.6%) was in hospitals with pharmacy-coordinated unit dose and drug administration programmes. • Despite safety considerations, the unit dose drug distribution system makes it difficult for nurses to respond to rapidly changing drug therapy orders. • In a review of medication error rates using observation-based studies, it was noted that error rates in hospitals ranged from 4.4% to 59.1% if wrong time errors were included and from 0.4% to 24.7% if wrong time errors were excluded. • It was further noted that lower error rates were consistently noted (typically 50% lower) in hospitals using unit dose drug distribution systems compared to those using floor stock systems. •
- 13. • As a result, automated dispensing cabinets (ADCs) that enable secure storage of medications in the patient care area have been developed. • In fact, hospitals in the US are increasingly changing from centralised unit dose drug distribution systems to decentralised systems using ADCs. • A large majority of US hospitals (83%) now use ADCs as part of their medication distribution systems. • Studies have confirmed that if access to medications is possible before the pharmacist reviews the medication order, ADCs are error-prone. • Barker and Allen compared error rates in a system where medications were available for administration from a unit-based ADC that was not integrated with a computerised medication profile to a traditional unit dose system.
- 14. • The error rate in the unit-based, ADC was 16.3% compared to 5.4% with the unit dose system. • Borel and Rascati compared medication error rates before and after implementing a medication profile- linked version of an ADC. • The error rate with the unit dose system used before the ADC system was implemented was 16.9%. • The error rate for the profile-linked, unit-based system was 10.4%. Therefore, an important safe medication use practice is to require a pharmacist review of orders for medicines before they can be obtained from any supply and the dose is administered to a patient.
- 15. • It would appear therefore that medication errors are relatively common, and error rates are influenced by the drug distribution system. • Unit dose systems are still considered safer than floor stock systems. • ADCs that place medicines in the patient care area can be less safe if not properly configured with links to computerised medication profiles that include a pharmacist review. • The safest system is an integrated unit dose, drug administration programme with a high level of procedural standardisation and double checks, such as reviewing transcription accuracy, rescheduling missed doses, and regular review of the medication administration record to verify that medications have been administered as scheduled.
- 16. Causes of Medication Errors • In an analysis of the systems failures associated with ADEs and potential ADEs, errors were classified according to proximal cause by a multidisciplinary team of physicians, nurses and pharmacists. • In the review, 334 errors were detected as the cause of 264 preventable ADEs and potential ADEs. • Sixteen major systems failures were identified as the underlying cause of the errors. • The most common systems failure (29%) was in the dissemination of drug knowledge, particularly to prescribers. The next most common system failure was inadequate availability of patient information (18%) such as laboratory tests. • Seven systems failures accounted for 78% of all errors, all of which the authors state could be improved by better information systems.
- 17. • The stage of the medication use process associated with these ADEs was also determined. • Problems at the prescribing stage were most common (39%), followed by drug administration (38%) and dispensing (11%). The most common error type was wrong dose (28%) followed by wrong drug (9%), known allergy (8%), missed dose (7%) and wrong time (7%). Lesar et al. have studied medication prescribing errors in a teaching hospital. • From a total of 289,411 medication orders written during a one-year period, 905 prescribing errors were detected and averted by pharmacists. • The overall detected error rate was 3.13 errors for every 1000 orders written and a rate of 1.81 significant errors per 1000 orders. The most common medication classes involving errors were anti- microbials (28.5%), cardiovascular (10.7%), gastrointestinal (8.8%) and benzodiazepines (7.7%). The types of medication errors detected included:
- 18. • Overdose – 28.7% • Missing information – 22.3% • Underdosing – 17.8% • Wrong dose form ordered – 7.3% • Allergy to ordered drug – 6.7% • Duplicate therapies – 5.5% • Wrong drug ordered – 5.5% • Wrong route ordered – 3.4% • Wrong patient – 1.1%
- 19. • A subsequent study by Lesar found the prescribing error rate to be 3.99 errors per 1000 orders. • The most common specific factors associated with errors included: decline in renal or hepatic function requiring alteration of drug therapy (13.9%), patient history of allergy to the same medication class (12.1%), using the wrong drug name, dosage form or abbreviation (11.4%), incorrect dose calculations (11.1%), and atypical or unusual and critical dosage frequency considerations (10.8%). • The most common groups of factors associated with errors were those related to the knowledge and application of knowledge regarding drug therapy (30%) or patient factors that affect drug therapy (29.2%), use of calculations, decimal points or unit and rate expression factors (17.5%), and nomenclature factors (13.4%). • These data highlight the importance and need for a review of drug orders by pharmacists to detect and prevent errors before a dose is obtained and administered to the patient.
- 20. Cost of these Problems • Schneider et al. studied the cost of medication-related problems at a university hospital. • The charts of patients who had experienced an ADE were reviewed and the cost of treating the events was tabulated. Mean cost incurred for the management of ADEs included: additional laboratory tests ($95), non-invasive procedures ($184), additional medication treatment ($227), invasive monitoring or procedures ($2,505), increases in length of stay ($2,596), and transfer to an intensive care unit ($2,640). • It was estimated that the annualised total cost of ADEs was $1.5 million.
- 21. • Classen et al. used a matched, case control model to compare the length of stay, added costs and attributable mortality associated with ADEs. • They found that mortality in cases where there was an ADE was 3.5% compared to 1.05% in matched control cases that did not. • Mean length of hospital stay was 7.69 days compared to 4.46 days in control patients. • The mean cost of hospitalisation was $10,010 in patients who experienced an ADE compared to $5,355 in case controls who did not. The extra length of stay attributable to an ADE was 1.74 days, resulting in added costs of $2,013. • They noted that based on the number of ADEs detected in one year, the direct hospital costs were $1,099,413.
- 22. • Bates et al. assessed the additional resource utilisation associated with ADEs. • They also used a case control method and compared the cost of care for patients who experienced an ADE to matched control cases with the same diagnosis who were on the same service, but did not experience an ADE. • They too found an increase in length of stay, with patients who experienced an ADE being in the hospital for 2.2 additional days. • The increase in cost associated with an ADE was found to be $3,244. For preventable ADEs, the increase in length of stay was longer (4.6 days), and increase in costs was higher ($5,857). They estimate the cost of ADEs and preventable ADEs in their 700-bed teaching hospital to be $5.6 million and $2.8 million, respectively
- 23. Tools to Measure the Performance of the Medication Use • Process How do we detect medication errors so that safety improvement goals can be established and the changes made to improve medication safety be evaluated? • Errors occur at all steps in the medication use process, and measurement systems should be designed to evaluate each step. • Voluntary medication error reports often focus only on the drug administration step, making the assumption that there are no errors at the prescribing step. • Nurses can be very sensitive that medication error reporting programmes focus only on what they do when they administer a medicine, and ignore errors at other steps. In reality, errors can occur at all steps in the medication use system.
- 24. • Voluntary, self-reporting systems also often miss medication errors. Investigators have evaluated other ways to detect medication errors and ADEs, including chart reviews, computer screening and combinations of methods that can improve detection. • Even the best combinations of reporting systems miss many errors and events. As long as problems with the use of medicines are discovered and opportunities to improve the medication use system can be identified, it is a method that has value. • In spite of the limitation of under- reporting, a voluntary reporting system can still be a very good method to monitor performance because it is not time consuming and it engages the staff. • When healthcare professionals report errors or adverse events, there is recognition that a mistake has happened and a willingness to improve the process. • Observation-based studies are often perceived as ‘catching people doing things wrong’. It can be difficult to motivate the staff to admit that they have made an error because of the fear of punishment.
- 25. • In contrast to voluntary reporting programmes, observation-based studies are much more quantitative – they detect all errors that occur during an observation period. • They do not, however, detect rare events. If really serious events only happen five or six times a year, these errors are not likely to be detected from a small statistical sample when activities are observed. • On the other hand, if the impact of a change made to reduce medication errors is being studied, a more quantitative measurement method than voluntary reporting is needed. • A way to do this is a ‘before and after’ evaluation of the impact of the change to see if there are fewer medication errors. • An example of a medication safety goal might be to reduce the number of intravenous antibiotics administered at the wrong time (‘late doses’). A voluntary reporting system would be much less likely to be able to show that improvement resulted from change(s) compared to an observation-based study of the administration of intravenous antibiotics.
- 26. • Criteria-based audits, also known as medication use evaluation studies, are a third way to find opportunities for improvement. • When a problem is suspected, a study using chart review to collect data can provide a quantitative assessment of the problem. • An example is a warfarin medication use evaluation study. It might be found for example through chart review that many physicians use the wrong laboratory test to monitor warfarin therapy (for example, partial thromboplastin time or PTT instead of prothrombin time (PT) or International Normalised Ratio (INR)) or that patients with high INR values are treated too often with fresh frozen plasma instead of safer and less expensive vitamin K. • These types of findings would provide excellent examples of medication safety problems that need to be solved.
- 27. • Computerised detection programmes have emerged as an effective way to detect medication errors and ADEs. • Classen et al. have described a computer ADE monitor that integrates clinical and drug information in a way that allows physicians and pharmacists to detect errors more quickly. • Alerts are built into their rules base that identifies medication errors. Examples include orders for naloxone, vitamin K, fresh frozen plasma and potassium exchange resins. • These orders are very likely to be associated with medication errors. This method is sometimes called the ‘trigger tool’ because certain laboratory tests or drug orders ‘trigger’ an alert that an ADE might have occurred. • It is also important to note that computer ADE monitoring systems only detect events that result in abnormal laboratory values or the use of antidotes. • Not all ADEs result in this and are therefore not detected by computer detection systems. These are all good ways to identify errors without waiting for an incident report, but build on a voluntary reporting system.
- 28. • Jha et al. compared the rate and type of ADEs identified using a computerbased monitor to those discovered by chart review and by asking physicians, pharmacists and nurses for voluntary reports of ADEs. • The computer-based monitoring programme identified alerts, which were situations suggesting that an ADE might be present–for example, an order for an antidote such as naloxone. • A trained reviewer examined the chart to determine whether an ADE had actually occurred. • The number and types of ADEs discovered with this system was compared to those discovered by chart review alone and by voluntary reports by nurses and pharmacists. • The computer monitoring programme identified 2,620 alerts in eight months for patients on nine medical and surgical wards in a tertiary care hospital. Chart review alone found 398 ADEs and there were 23 voluntarily reported.
- 29. • Of the 617 ADEs detected by at least one method, only 76 were detected by both computer and chart review methods. • The types of events detected by chart review were different from those detected by computer monitoring. • Chart review was more effective in detecting symptomatic events, such as a change in mental status, nausea and vomiting, and hypotension. • The computer monitor was more reliable in identifying events associated with changes in laboratory monitoring or events that required treatment with medications. • Using a combination of these techniques, the incidence of ADEs was found to be 17.8 per 1000 patient days.
- 30. What Can Pharmacists Do to Improve Medication Use Safety? Traditional methods • Unit dose drug distribution systems: The first study to demonstrate that medication errors were a relatively common occurrence was published in 1962. • The error rate in this study was found to be 16.2%. Subsequently, these investigators and others studied the impact of providing medicines that were packaged, labelled and distributed to the point of care for administration within 24 hours or less (the unit dose drug distribution system). • It was shown that significant improvement could be achieved by a unit dose system, if fully implemented. • Studies cited in this review have shown that error rates can be paradoxicallyhigherwhen compromises such as dispensing multi dose containers, increasing cart exchange rates and increasing floor stock were made.
- 31. • With the increased interest in ADCs, the unit dose drug distribution system has been challenged as the standard of practice in hospitals. • Improperly configured, these dispensing cabinets can be less safe than unit dose drug distribution systems (see below). Until the safety of properly configured systems can be demonstrated, unit dose drug distribution systems remain a fundamentally safer system than floor stocked medications. • Intravenous admixture systems: Concerns about the safety of medicines administered by the intravenous route also began to be expressed in the 1960s. • Patterson and Nordstrom reported that 60% of IV solutions being infused to hospitalised patients contained more than one medicine – some as many as five drugs. More than half the medicines were prepared more than an hour before administration.
- 32. • A pharmacy-based, intravenous admixture programme was proposed. • Thur et al. reported an error rate of 21% in a system where nurses prepared and administered IV medicines. • An error rate of 7.24% in a pharmacy-based IV admixture service has been described. It has also been shown that physicians and nurses make more errors in dosage calculations compared to pharmacists. • The uniformity of mixing when IV solutions are prepared at the bedside is lower than that when they are prepared in the pharmacy. Schneider has reviewed the safety of intravenous drug delivery using the following systems: • IV push (nurses prepare and administer the dose directly using a syringe) • Volume control chambers (a container between an IV solution and the IV tubing into which medicines can be added for infusion)
- 33. • Pharmacy prepared minibags/glass bottles (medicines are added to a small volume of IV fluid under sterile conditions in the pharmacy) • Spring-loaded syringe-based system (a device that uses a spring to put pressure on the plunger of a syringe to facilitate delivery of a dose) • Point-of-care activated system (ADD- VantageR, Minibag PlusR) (a plastic bag containing IV fluid and a special port for directly attaching a vial of medicine for mixing at the bedside) • Outsourced piggyback systems (a central pharmacy prepares IV containers containing medicines and delivers these to the hospital for use) • Manufacturer’s container (a glass vial that allows for reconstitution of the dose and direct administration to the patient from the vial using an IV set) • Premixed and frozen minibags (pre- made IV solutions containing the medicines, some of which are frozen because of limited stability)
- 34. • Using a decision analysis model derived from the consensus development method used by the US National Institutes of Health, these systems were compared by an independent, interdisciplinary panel of experts. • Their recommendations were based on comparing these systems using four criteria: safety, cost, simplicity and training. Three systems were ranked as being safer – manufacturer prepared (premixed and frozen minibags), point-of-care activated and pharmacy-based IV admixture systems. • Systems ranked less safe included IV push, syringe pumps and volume control chambers. It was noted that clinical circumstances may require a less safe system (for example, during a medical emergency). • In those cases, increased vigilance is needed to assure safety. The results of a summit on preventing patient harm and death from IV medication errors was recently published.
- 35. • It lists priority IV medication safety practices along with barriers to implementation and actions to overcome these barriers. • Some examples of priority practices according to steps in the medication use system include: • Formulary management and medication use policy • Implement standardised infusion concentrations based on local and national practices that are appropriate for most practice settings • Establish comprehensive IV medication administration policies with standardised administration times, upper and lower dosage limits, and administration rates • Prescribing and ordering • Use standardised orders (paper or electronic) for IV medicines • Prescribe standardized infusion diluents, concentrations and units (preferably commercially available products)
- 36. • Storage • Differentiate look-alike medicines, including separate storage locations Prohibit or impose tight security precautions on stocking concentrated injectable products and more than one concentration of an IV medicine on patient care units • Preparation and dispensing • Dispense IV medicines in a ready-to- administer form that does not require manipulation before administration to the patient • Standardise the process for compounding sterile preparations, with procedures to minimise unnecessary interruptions and distractions, trace and verify the accuracy of compounding, and provide for pharmacist checking of accuracy • Administering
- 37. • Require independent double-checks and documentation of administration of selected high-alert medicines, including IV pump settings Standardise IV medication administration with provisions to minimise unnecessary interruptions, focus on one patient at a time, refer to an accurate medication administration record, engage the patient or family member in the medication administration process, and use two patient identifiers before administering the medicine • Monitoring medication use • Have antidotes, supportive medicines, dosing and administration information and resuscitation equipment immediately available in patient care areas • Establish standard operating procedures for communication at the time of patient transition from one care setting to another to provide for continuity of care and medication reconciliation
- 38. Clinical Pharmacy Programmes • The positive impact of pharmacist participation on medical rounds in an intensive care unit on the rate of preventable ADEs caused by ordering errors has been reported. • In this study, a pharmacist made rounds with the ICU team and remained in the ICU for consultation in the morning and on call throughout the day. • The rate of prescribing errors decreased by 66% from 10.4 per 1000 patient days before the intervention to 3.5 per 1000 patient days after the intervention. • In a control unit, the incidence of ADEs did not change. In eight months, 366 recommendations were made by the pharmacist, of which 362 (99%) were accepted by the prescribers.
- 39. • There is also evidence of improved patient safety by clinical pharmacists practicing in the outpatient setting. • Lee and Schommer documented a fivefold decrease in bleeding complications and re-admission to the hospital associated with anti-coagulation management, comparing a pharmacist- run anti-coagulation management service to regular medical care. • Pharmacists have also been able to reduce the number of errors of omission (improve adherence to medication treatment regimens) to improve the outcomes of patients taking medications to lower cholesterol and treat diabetes in the outpatient setting.
- 40. Application of Technology • The emergence of new technology offers great potential to improve both the efficiency and the accuracy of care, resulting in improved patient safety. • Technology and automation also have the potential to worsen patient safety or simply change the type of patient safety problems if not properly used. • Computer prescription order entry (CPOE) system: This is a computer application that accepts the prescriber’s orders for diagnostic and treatment services electronically rather than recording them in writing on an order sheet or prescription pad. • This includes orders for medications. The computer can compare the orders against standards for dosing, check for allergies or interactions with other medications and warn the prescriber about potential problems. Thus, CPOE systems address two of the most common systems failures causing errors: lack of information about the medicine and lack of information about the patient.
- 41. • CPOE has been widely recommended as a way to improve patient safety. A medication safety expert panel assembled by ASHP recommended this as the top-priority action to prevent ADEs in hospitals. • There are several advantages of CPOE that have the potential to improve medication use safety. Handwriting problems are solved, resulting in fewer transcription errors. • The prescription can be quickly transferred to providers, reducing delays in dispensing and initiating therapy. • Decision support logic and integration with other relevant clinical information can be built into a computer order entry system to assist physicians in avoiding errors.
- 42. • The impact of a computer order entry system on antibiotic therapy has been documented by Evans et al. • They studied the prescribing of antibiotics in an intensive care unit where orders were entered into a computer program that was linked to clinical information and provided the prescriber with recommendations and warnings about drug therapy. • Significant reduction was observed in antibiotic susceptibility mismatches before and after the computer program was implemented (12 vs. 206). • Fewer antibiotics were prescribed for patients with known allergies to those drugs (35 vs. 146). • The incidence of overdoses and mean number of days of excess treatment were lower (87 vs. 405 and 2.7 vs. 5.9), as was the incidence of ADEs (4 vs. 28). Most importantly, a safer system reduced the total hospital cost to the patient ($26,315 vs. $44,846).
- 43. • Bates et al. reported the effect of computer order entry and team intervention on the prevention of serious medication errors. • They found that providing a computerised order entry system along with a team-based intervention programme that increased the availability and role of the pharmacist reduced serious medication errors by 55%, from 10.7% per 1000 patient days to 4.86 events per 1000 patient days. • If improperly configured or implemented, CPOE systems may facilitate the risk of medication errors. Koppel et al. reported about 22 types of medication error risks resulting from a CPOE system, including: • Fragmented CPOE displays that prevent a coherent display of patients’ medications • Pharmacy inventory displays mistaken for dosage guidelines • Ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system • Separate functions that facilitate double-dosing and incompatible orders • Inflexible ordering formats generating wrong orders
- 44. • CPOE, like all technologies, is a tool, not a solution to medication errors, and must be designed and implemented carefully to realize benefits. • The use of CPOE systems in US hospitals has grown slowly but steadily. In 2007, 17.8% of US hospitals had a CPOE system. • The rate of adoption of CPOE differed significantly by type and size of facility. • Clinical decision support systems (CDSSs) are important components of CPOE, directing prescribers toward evidence- based drug therapy. • Of those hospitals with CPOE, 67.2% had CDSSs in use to improve prescribing. Nearly one-third of hospitals with CPOE systems did not have a CDSS.
- 45. • In these facilities, clinicians entered orders into electronic systems that did not have rules that integrated order information, patient information and clinical practice guidelines into computer system logic to provide feedback to prescribers. • Therefore, it was estimated that 12% of US hospitals at the end of 2007 had CPOE with a CDSS. • The use of computer order entry systems in the outpatient setting has been limited by the lack of a network of providers and an electronic infrastructure connecting them. • Workflow does not favour having prescribers enter prescriptions in the office setting. • The increase in networking providers and the rapid growth of wireless communication will very likely fuel the development of computer order entry in the outpatient setting. • Despite the seeming consensus that this is an important change concept, rapid implementation has been, and will continue to be, limited by expense, design of decision support systems and the difficulty in changing the habits of prescribers.
- 46. • Bar code, bedside care systems:The second recommendation from the medication safety expert panel assembled by ASHP to recommend toppriority actions for preventing ADEs in hospitals was evaluating the use of machine readable coding (for example, bar coding) in their medication use processes. • In 2008, 24% of hospitals used some form of machine readable coding to verify doses before dispensing, and 21.5% of US hospitals had barcode medication administration systems (BCMA) at the bedside in place. • Bar code systems are particularly suited for efficient and accurate checking functions. • It has been suggested that the checking and documentation functions that occur when medications are dispensed and administered could be done more efficiently and accurately if aided by bar code scanning.
- 47. • This application would include having bar codes on the package of each medication dispensed and administered, on a patient identifier (such as a wristband), and on the person dispensing and administering the dose (such as a name badge). • A BCMA can be linked to clinical information and the medication profile, so that when the dose is dispensed and administered to a patient, an automatic check could be made to ensure that the drug was prescribed for the correct patient, the dose, time and route of administration is correct, and that the patient does not have an allergy to the medication being dispensed and administered. • The nurse could even be reminded to administer a dose with such a system. In addition to improving safety through these series of automatic doublechecks, the documentation of the dose dispensed and administered would be improved. Furthermore, performance measurement systems such as late doses and doses omitted could automatically be tracked, reducing the dependence on voluntary reporting or observation-based studies.
- 48. • Poon et al. reported that a bar code- assisted dispensing system decreased dispensing errors by 86% and potential ADEs by 97%. • Paoletti et al. reported a 54% reduction in medication administration errors after implementing a new medication administration system that included BCMA. • Barriers to implementation of the bar code bedside care system include cost, the need to use cumbersome equipment, lack of universally bar-coded medication packages, lack of standardisation of bar code languages, and problems linking bar code systems to other hospital computer databases and programs.
- 49. • Integrated clinical information systems: Information systems within healthcare are often configured as standalone systems that meet the needs of individual departments, but can be difficult to integrate. • The healthcare industry has under-capitalised information systems in comparison to other industries. The result is fragmented information and difficulty obtaining the complete clinical information needed to care for patients. • Physicians often do not have access to medication profiles. Pharmacists often do not have access to diagnosis, weight, organ system function or allergy history. As a result, medication-related problems occur. • Advances in technology and increased consolidation and integration among healthcare providers are resulting in rapid integration of clinical information systems. • Two examples of advances in technology are the Internet and smart cards
- 50. • Each of these technologies is enabling the storage and transfer of large quantities of clinical information efficiently among caregivers. • Concerns about confidentiality of information have been raised as efforts to transmit clinical information have increased. • It is imperative that clinical information among caregivers who do not practice in contiguous sites and see patients at different times be integrated. • Only with access to complete information about why the patient is being treated, previous experiences with medications, and conditions, medications and foods that may affect the choice or responses to pharmacotherapy, can medication safety be improved.
- 51. Implications for Pharmacists in India • India is a rapidly developing country but may still not have the resources that exist in countries that have created and evaluated safe medication use systems. • It is unrealistic to expect the rapid adoption of expensive technologies that can improve patient safety, such as CPOE and bar code systems. • It is also a country with more variation in how healthcare is provided, including the use of homeopathic and ayurvedic medicines in addition to the allopathic medications used more commonly in the West. • This variation might result in even more problems with medication errors resulting from interactions among these different medications.
- 52. • While there are more pharmacists in India than most other countries, most do not practice in settings where they can work closely with prescribers or nurses to discuss medication- related problems and develop safer medication use systems. • Where should pharmacists in India begin? Perhaps some lessons can be learned from the experience of other countries. Some suggestions include: • Acknowledge that medication errors and ADEs occur and are a problem in India. Part of this realisation might include studying the problem of medication use safety and developing methods to detect errors and ADEs in hospitals and clinics. • Declare that improving medication use safety is a serious and dedicated aim for pharmacists in India. This might be accomplished by adding this topic to coursework in pharmacy colleges and as a focus for discussion at meetings of the pharmacy associations in India.
- 53. • Use your experience to identify medication errors that frequently cause patient harm and focus attention on finding ways to improve the system so that those errors are less likely to happen again. Attention should be directed to errors that are most common, most likely to cause harm and least likely to be detected before harm occurs. An example of such an error is having toxic medications (like concentrated solutions of potassium chloride) available as floor stock in a hospital. An example of a medication that can result in harm if errors occur in outpatients is the anti-coagulant warfarin. • Critically examine each step of the medication use process in your hospital or pharmacy and identify areas where the risk of medication errors can be minimised.For example, transcription of drug orders is common in many Indian hospitals and is a well- recognised cause of medication errors. Some other potential causes of medication errors in India are listed in Table 28.1. • Begin by making the improvement of medication use safety an individual pharmacist’s duty, day by day and patient by patient.