Brooke D. Fidler, PharmD, CDM
assistant professor of pharmacy
practice, Arnold & Marie Schwartz
College of Pharmacy and Health
Sciences,
Long Island University

Patient safety/reducing
medication errors

INTRODUCTION

The “Five Rights” of medication safety learned by pharmacists include giving the right drug to the right patient in the right dose by the right route at the right time. Unfortunately, adhering to these goals may not be sufficient to assure patient safety and minimize medication errors.

It is estimated that more than 7,000 deaths occur annually from medication errors, which are just one form of medical error that can occur. ¹ A medical error is defined as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” ² This number exceeds deaths due to motor vehicle accidents, breast cancer or AIDS, making medical errors the fifth leading cause of death in the United States. ¹ Although many people may assume that medical errors are limited to medications, in fact they also encompass diagnostic errors, equipment failure and post-surgical infections. ² According to the Institute of Medicine (IOM), as many as 98,000 Americans die each year from medical errors. ¹

Pharmacists should be aware of the problem posed by all forms of medical errors. However, it is in the area of medication errors where pharmacists should not only be aware, they also must be prepared to take action to minimize errors and thus assure patient safety. The National Coordinating Council for Medication Error and Prevention (NCC MERP) defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare professional, patient or consumer.

Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.” ^{3, 4} The cost of drug-related mortality and morbidity is estimated at $77 billion. ⁵ One study found that medication errors in an outpatient Medicare group resulted in annual costs of $887 million. ⁶ These total costs do not take into account indirect costs, such as loss of workdays, lost wages, disability and other health costs.

Injuries due to medication errors affect not only patients but also their families, employers, hospitals, healthcare providers and insurance companies. Other consequences of medication errors include dissatisfied patients, worsening of health conditions and pain or suffering.

Historically, the primary focus of medication error data collection has been on hospital settings. However, some community pharmacy data is available. Results from a prospective study in a community pharmacy found that for every 10,000 prescriptions dispensed, there were 22 near misses (defined as an event that did not produce patient injury) and four dispensing errors. ⁷ Selecting the wrong drug, labeling and bagging errors were the most common types of incidents identified.

Errors have the potential to originate at any stage in the medication-use process, which includes prescribing, documenting, dispensing, administering and monitoring. ^{5, 6} The responsibility to prevent errors and promote patient safety lies with the manufacturer,

prescriber, pharmacist and patient. Community pharmacists should be able to identify potential causes of error; implement approaches to prevent errors; utilize appropriate communication skills with prescribers; pharmacy staff and patients; and provide reporting of errors to healthcare agencies when they occur.

ERROR: A FAILURE OF QUALITY

In 1996, the IOM implemented the Quality of Care Initiative with the intent of improving the quality of care in America. The IOM defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes.” ⁸ Medication error is considered a failure of quality.

The IOM has released 17 reports over the last 10 years focusing on awareness of patient safety and standards of health care. In 1999, the first of these reports, To Err is Human: Building a Safer Health System, focused on ensuring a safer healthcare system by increasing public awareness of medical errors and strategies for improvement. A primary theme of this report is avoiding individual blame when errors are made. Although human error does exist, the majority of errors are caused by faulty systems and environments that enable or allow people to make mistakes. Preventing future errors requires the ability to identify problems in the overall system and correct them. According to the IOM, “errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.” ¹

In 2001, Crossing the Quality Chasm: A New Health System for

Universal Program Number: 401-000-08-006-H05 Initial release date: June 1, 2008

Planned expiration date: April 15, 2011

This program is worth two contact hours

(0.2 CEUs).

Target Audience

Pharmacists in community-based practice.

Program Goal

To improve pharmacist’s ability to assure patient safety and minimize medication errors.

Learning Objectives

Upon completion of this program, the pharmacist should be able to:

1. Define medication errors as a failure of quality.

2. Explain root cause analysis as a means to identify and minimize common risks within community pharmacy that may contribute to a failure of quality.

3. Implement error reduction and prevention measures designed to improve patient safety.

4. Educate patients and caregivers on patient safety activities useful in medication administration.

5. Document improvement in patient safety, based on medication error reduction.

To obtain credit: Answer the questions at the end of this lesson on the answer sheet provided. If you are submitting your answers by mail or fax, completely fill in the circle corresponding to your answer with a black pen (no pencils or blue pens please). A statement of credit will be sent to participants achieving a minimum score of 70 percent correct responses. Statements of credit are issued within seven days of receipt, if submitted by mail or fax, and immediately, if submitted online. TO LINK DIRECTLY TO THIS LESSON CLICK www.cedrugstorenews.com/40100008006H05

Questions regarding statements of credit and other customer service issues should be directed to Angela Sims at (800) 933-9666. Include your seven-digit CEQ enrollment number on the answer sheet. (The seven-digit number immediately to the right of the letters CE on the first line of the label.) Fax to (813) 626-7203 or mail completed answer sheet to Drug Store News, P.O. Box 31180, Tampa, FL 33631-3180. Programs also may be completed online at www.cedrugstorenews.com. If you are a paid enrollee, there is no cost to participate in this lesson. The fee for participants who are not enrolled is $10.95.

Florida approval nuumber: 20-184196

Drug Store News is accredited by the Accreditation Council for Pharmacy Education

(ACPE) as a provider of
continuing pharmacy education.