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Medication safety: A complex puzzle


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The National Quality Forum (NQF) included modifications to the medication management chapter in its Safe Practices for Better Healthcare-2009 Update. By combining four existing practices into one, the NQF has called for increased leadership and accountability on the part of hospital pharmacists.

Medication management has been a part of the NQF's Safe Practices since they were released in 2003. Safe Practices 17 and 18 concern medication safety.

"I can't think of one area that is more complicated to try and hit the right balance of," said Peter B. Angood, MD, FRCS(C), FACS, FCCM, senior advisor to the NQF on patient safety and former vice president and chief patient safety officer at The Joint Commission. Angood spoke during the June 18 Webinar "Medication Safety: Complex Issues for All," hosted by the NQF and Texas Medical Institute of Technology. "The difficulty comes with the fact that these are common problems but highly complex in terms of finding solutions," Angood said, adding that many organizations struggle with crafting policies that encourage change in the medication management process.

The statistics are well known, yet still shocking: 1.5 million people are harmed each year due to medical errors. In hospitals, about one medication error per patient is made each day. Michael Cohen, RPh, MS, ScD, president of the Institute for Safe Medication Practices (ISMP), which assists Pennsylvania with its mandatory incident reporting system, said that 26% of the state's reported errors were medication errors.

In the past 10 years, many efforts have been made to improve medication safety, said Cohen. Beginning with the Institute of Medicine's To Err is Human in 1999 and including the original publication of NQF's Safe Practices, the subsequent updates, and The Joint Commission's Sentinel Event Alerts concerning medication errors, the field has learned a lot about why medication errors occur. "It's something we've preached almost from day one—that is the true need to be proactive and not wait for incidents to occur," said Cohen of the ISMP's efforts.

He highlighted progress that has come out of collaboration among patient safety groups and learning from mistakes and areas that the healthcare industry still needs to improve on. Communication problems with drug information often lead to medication errors. The field has adapted by highlighting medications that look and sound alike, and the pharmaceutical industry has responded by developing drug names that are not similar to others.

"Our FDA actually requires that names of drugs being developed by the pharma companies, before they can even apply with their new drug application, they actually have to be tested now by practitioners," said Cohen. "We've begun to see fewer of these drug name pairs that wind up needing a name change." Other common communication errors relate to abbreviations and dose designations, misunderstood or omitted medication suffixes, and differences in how the drug is referred to in international, laboratory, and over-the-counter settings.

Healthcare has created some successful fixes to prevent medication errors but needs to be more vigilant about using them. These include:

  • Encouraging the use of "tall man" lettering with medications that look or sound alike as a means of differentiating when written out
  • Ensuring a read-back of verbal medication orders, versus a repeat-back, so staff members can double-check their actions
  • Communicating with pharmaceutical vendors about the need to modify look-alike packaging
  • Standardizing drug concentrations (avoiding use of confusing concentrations, such as 20mg/ml vs. 100mg/5ml, decreases the likelihood of a medication error)


Cohen also emphasized the need for hospitals to get patients involved with their medication safety. The ISMP created a Web site for the general public in 2008 to inform patients how they can ensure that their hospital stays are safe. It hopes hospitals will publicize the site (www.consumermedsafety.org) with their patients to add another level of patient safety.

Increased leadership by pharmacists to prevent medication errors
Pharmacists should have a greater presence on the leadership team to help navigate the increasingly complicated world of medication management, said Mary Andrawis, PharmD, MPH, director of clinical guidelines and quality improvement at the American Society of Health-System Pharmacists. To ensure that the existing practices to prevent medication errors and develop new ones continue, pharmacists will be an important piece of the puzzle.

"Literature shows that when pharmacists are involved in care, the result is improved patient care, fewer adverse events, and reduced costs," said Andrawis, speaking about Safe Practice 18. "But in order for that full benefit to be realized, it's really important that those pharmacists be given appropriate authority and, consequently, that they continue to take accountability for patient outcomes."

Greater integration of pharmacists with the healthcare team not only helps the organization provide more efficient care, but, more importantly, increases patient safety because of greater pharmacist availability to be involved in the decision-making associated with care, said Andrawis.

She presented steps facilities can take to boost medication safety:

  • Open the lines of communication between the leadership team and the hospital's pharmacists. Pharmacists want to have a greater role in decision-making and can also best explain how medication management can lower the facility's costs, Andrawis said. She gave the example of a new service opening up within the hospital. "It's really the pharmacy leader that can best anticipate any disruptions or changes that might [affect] the medication use system from other decisions that are made," she said.
  • Create a medication safety committee. Led by a pharmacist, this committee can review errors, perform root-cause analyses related to medication errors, and brainstorm how to plug gaps in the medication system. This group should also be involved with any WalkRounds that take place, said Andrawis.
  • Make sure pharmacists are involved in technology planning and implementation. Today, many types of technology are used to manage medications in the hospital, including smart pumps, bar coding, and computer physician order entry. "I really believe the results could just be catastrophic if the technology is not planned for adequately and implemented safely," said Andrawis.
  • Include a pharmacist on the clinical team. Instead of referring to pharmacists at certain stages of the process, Andrawis encouraged hospitals to consider making the pharmacist part of the team, much like the nurse, doctor, and specialists. Doing so eliminates delays in care, promotes collaboration and better decision-making for each patient's care, and encourages a sense of shared responsibility for each patient, said Andrawis.


Source: Briefings on Patient Safety, August 1, 2009