Medication errors in United States hospitals

Pharmacist's interventions in factors contributing to medication errors reduces medication errors in self-management of patients in the rehabilitation ward

BACKGROUND

The number of medications, number of administrations per day, dosing frequency on indicated day, and medication from multiple prescriptions are the medication factors prone to medication errors in self-management that have been previously reported. However, whether pharmacists actually intervene in medication factors that affect medication error occurrences in self-management is unclear. Therefore, we conducted this study to clarify these issues.

METHOD

This study included patients who underwent self-management in the rehabilitation ward of Higashinagoya National Hospital. From April 2019 to March 2020, a one-pharmacist period existed, and from April 2020 to March 2021, a two-pharmacist period existed. The number of patient instructions and interventions were expected to increase with an increase in the number of pharmacists. Considering this to be an environment of differential interventions by pharmacists, a pre-post-test design was conducted with all self-managed patients in both the time periods. The primary and secondary endpoints were the proportion of medication error occurrences and proportion of pharmacist's interventions in medication factors, respectively.

RESULT

The proportions of medication error occurrences during the one-pharmacist and two-pharmacist periods were 41% (71/173) and 28% (51/180) (relative risk 0.690, 95% confidential interval 0.515-0.925), respectively. The proportion of pharmacist's interventions in medication factors in the one-pharmacist period was 13% (22/173) and 22% (40/180) in the two-pharmacist period; there was an increase in the proportion of pharmacist's interventions in medication factors in the two-pharmacist period.

CONCLUSION

The proportion of medication error occurrences was significantly lower in the two-pharmacist period than that in the one-pharmacist period. This can be attributed to the increase in the proportion of pharmacist's interventions in medication factors. Therefore, an environment in which pharmacists could intervene in the medication factors to prevent medication errors in advance is necessary.

Evaluating the role of clinical pharmacist in the detection and reduction of medication errors in a specialized burn unit

OBJECTIVE

This study evaluated the frequency and types of medication errors and the role of clinical pharmacist in the reduction of medication errors in a burn unit.

METHODS

The clinical pharmacist monitored medication use process in all patients admitted to the burn unit in the 4-month interventional study. Direct observation and chart review methods were used to detect medication errors. Medication errors were classified according to the classification of American Society of Health-system Pharmacists. The seriousness of medication errors was categorized based on the National Coordinating Council for Medication Error Reporting and Prevention index.

RESULTS

During the study, 1653 drugs were prescribed to 94 patients. Totally, 259 medication errors were identified. The rates of medication errors were 2.75 errors/patient, 0.16 errors/ordered medication, and 0.98 errors/prescription. The most common type of errors was prescribing error (61.8%) followed by dispensing error (14.7%). Regarding the seriousness of medication errors, 1.9%, 21.6%, 45.9%, 30.1%, and 0.4% of errors were in the categories B, C, D, E, and F, respectively. Antibiotics had the highest rate of errors. Of all detected medication errors, 64.5% were intercepted or corrected by the clinical pharmacist interventions.

CONCLUSION

Medication errors were not rare in the burn unit. Providing clinical pharmacy services to burn patients to reduce the incidence of medication errors is highly recommended.

The Role of Clinical Pharmacy in Preventing Prescribing Errors in the Emergency Department of a Governmental Hospital in Jordan: A Pre-Post Study

Background: Clinical pharmacists have a vital role in intercepting prescribing errors (PEs) but their impact within a Jordanian hospital emergency department (ED) has never been studied. Objective: To evaluate the impact of clinical pharmacy services on PEs and assess predictors of physicians' acceptance of clinical pharmacists' interventions. Setting: This study was conducted in the ED of the largest governmental hospital in Jordan. Method: This was a pre-post study conducted in October and November 2019 using a disguised observational method. There were 2 phases: control phase (P0) with no clinical interventions, and active phase (P1) where clinical pharmacists prospectively intervened upon errors. The clinical significance of errors was determined by a multidisciplinary committee. The SPSS software version 24 was used for data analysis. Main Outcome Measure: PEs incidence, type, severity, and predictors for physicians' acceptance. Results: Of 18003 patients, 8732 were included in P0 and 9271 in P1. PEs incidence decreased from 24.6% to 5.4%. Contraindication, drug selection, and dosage form error types were significantly reduced from 32.6%, 9.1%, and 3.7% (P0) to 12.6%, 0.0%, and 0.0% (P1), respectively. Albeit not statistically significant, drug-drug interaction, drug frequency, and allergy error types were reduced from 4.9%, 3.1%, and 0.1% to 4.5%, 2.5%, and 0.0%, respectively. Significant and serious errors were significantly reduced from 68.7% and 3.0% (P0) to 8.9% and 1.8% (P1), respectively. During P1, most errors were minor (89.3%, 1574/1763), and lethal errors ceased. Predictors for physicians' acceptance were: significant errors (OR 3.1; 95% CI 2.6-4.3; P = 0.03) and non-busy physicians (OR 2.1; 95% CI 1.6-2.7; P = 0.04). Conclusion: Clinical pharmacists significantly reduced PEs in the ED by 76%; most of interventions were significant. Policymakers are advised to implement active clinical pharmacy in the ED.

Knowledge and attitudes of healthcare professionals on prescribing errors

OBJECTIVES

This study aimed to evaluate the knowledge and attitudes of healthcare professionals on prescribing errors.

METHODS

This was a cross-sectional study employing a questionnaire that consisted of 12 items on knowledge and 10 items on healthcare professionals' attitudes toward errors in prescribing process. The participants responded to the questionnaire with a 5-Likert scale of agreement. The domains assessed in the questionnaire were respondents' knowledge and attitudes on prescribing errors, professionals responsible for the errors, and professionals' competence on drug dose adjustment. Additionally, the questionnaire had two case scenarios to further assess the healthcare professionals' knowledge of prescribing errors. There were 300 questionnaires administered to physicians, nurses, and pharmacists who attended conferences in Denpasar from July to October 2019.

RESULTS

There were 30 physicians, 58 nurses, and 69 pharmacists who responded to the survey. A response rate of 52.3% (157/300) was obtained. All healthcare professionals agreed that errors may occur in prescribing, dispensing, and administration process. All healthcare professionals understood that physician is responsible for ensuring drug safety in prescribing process and also supported a standardized form on drugs which may need drug dose personalization. Concerning item on the importance of collaboration in drug dose adjustment, although the healthcare professionals agreed on the statement, they had significant differences on the level agreement on the statement (p=0.029). The healthcare professionals also supported having regular training on drug dose adjustment based on individual patients' regimentation. The healthcare professionals' responses showed that the significant differences found on the statement of healthcare professionals should have competency on personalized dose calculation (p<0.001). All healthcare professionals agreed that physicians should have competency on drug dose adjustment, yet physicians showed less agreement that other health professionals should have the competency.

CONCLUSIONS

All healthcare professionals understood that medication errors may occur during the prescribing process but showed different attitudes on professionals who had competence in drug dose calculation. They emphasize the need to have a standardized prescription format for medication with dose changes. The respondents also recommend having regular training on medication safety for healthcare professionals.

Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit

BACKGROUND

Minimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.

OBJECTIVE

We assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.

METHODS

In this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).

RESULTS

After the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.

CONCLUSIONS

The implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.

Which drugs cause treatment-related problems? Analysis of 10,672 problems within the outpatient setting

Background

Treatment-related problems (TRPs) may pose risks for patients if unaddressed. With the increased complexity of health care, it is important to target pharmacists' efforts to patients that are at high risk for TRPs.

Objectives

The present study aimed to identify medications most commonly associated with TRPs.

Setting

Outpatient departments of five public and teaching hospitals in Jordan.

Method

TRPs and drugs most commonly implicated with TRPs were assessed for patients recruited from outpatient clinics in five major hospitals in Jordan using a standardized and validated pharmaceutical care manual.

Main outcome measure

Drugs associated with different types of TRPs.

Results

Ultimately, 2,747 patients, with a total of 10,672 TRPs, were included in the study. The medication groups most commonly associated with TRPs were cardiovascular (53.0%), endocrine (18.1%), and gastrointestinal (7.7%) drugs. The most common specific drugs associated with TRPs from any category were atorvastatin (12.5%), metformin (8.5%), simvastatin (6.2%), and enalapril (5.9%). Cardiovascular medications were the most common drugs implicated with multiple subtypes of TRPs - most commonly, allergic reaction or undesirable effect (88.5%), drug product not available (87.3%), safety interaction issues (81.8%), a need for additional or more frequent monitoring (78.0%), and more effective drugs available (77.2%). Hypertension, diabetes mellitus, and dyslipidemia were the most common diseases associated with different subtypes of TRPs.

Conclusion

The present study identified high-risk drugs for TRPs, which can be used as identification of targeting approach TRPs. Such an approach would improve care provided to patients and can inform health care policies.

Service design oriented multidisciplinary collaborative team care service model development for resolving drug related problems

Our goal was to help prevent drug-related morbidity and mortality by developing a collaborative multidisciplinary team care (MTC) service model using a service design framework that addressed the unmet needs and perspectives of diverse stakeholders. Our service model was based on a “4D” framework that included Discover, Define, Design, and Develop phases. In the “discover” phase, we conducted desk research and field research of stakeholders to identify the unmet needs in existing patient care services. We used service design tools, including service safaris, user shadowing, and customer journey maps to identify pain and opportunity points in the current services. We also performed focus group discussions and in-depth interviews with stakeholders to explore the needs for improved services. In the “define” phase, we generated the service concept by mind mapping and brainstorming about the needs of stakeholders. The service concept was defined to be a Patient-oriented, Collaborative, Advanced, Renovated, and Excellent (P-CARE) service. We named the service “DrugTEAM” (Drug Therapy Evaluation And Management). In the “design” phase, we designed and refined four prototypes based on results from validation tests for their application towards following services: 1) medication reconciliation, 2) medication evaluation and management, 3) evidence-based drug information, and 4) pharmaceutical care transition services. During the “develop” phase, we implemented four services in a longitudinal chronic care model, considering the time spent by patients for each inpatient and outpatient setting. In conclusion, this is a study to develop a collaborative MTC service model using service design framework, focused on managing the unmet needs of patients and healthcare providers. As a result of implementing this service model, we expect to strengthen the professional relationship between pharmacists and stakeholders to ultimately create better patient outcomes.

Problems, interventions, and their outcomes during the routine work of hospital pharmacists in Bosnia and Herzegovina

Background In the last 30 years, activities of hospital pharmacists have gone through significant changes. Pharmacists are increasingly involved in patient care. Objectives To explore drug-related and logistic problems, interventions, and their outcomes during routine everyday work of hospital pharmacists. Setting Institute for physical medicine and rehabilitation, Banja Luka, Bosnia and Herzegovina. Methods In the period of January 2013-October 2015 a prospective observational study was performed. Medical doctors, nurses, therapists, and patients addressed pharmacists, face-to-face or by telephone, with drug-related problems (DRPs) and/or logistic issues. Main outcome measure Type of DRP or logistic issue, intervention, outcome, initiator and time spent for solving the problem were documented for each consultation. Results Out of 1515 interventions, 48.8% were aimed at solving DRPs. The most common DRPs were the recommendation of a drug or dose and need for additional information about drugs. Drug price and supply were the most prevalent logistic issues. DRPs were more frequently initiated by medical doctors and required more time to solve the problem compared to logistic issues (Mann-Whitney U test, p ≤ 0.001, respectively). The acceptance rate of interventions to solve DRPs (83.7%) was lower compared to logistic issues (95.2%; p ≤ 0.001). Conclusions Hospital pharmacists were faced with an approximately equal number of DRPs and logistic issues during their routine everyday work. The overall acceptance rate of pharmacists' interventions was high, and the results of our study indicate that there is a need for more involvement of hospital pharmacists in Bosnia and Herzegovina in clinical activities. Impact on practice.

[Medication errors in a neonatal unit: One of the main adverse events]

INTRODUCTION

Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented.

MATERIAL AND METHODS

An analysis was performed on the ME declared in a neonatal unit.

RESULTS

A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed.

CONCLUSIONS

It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.

Knowledge and competence with patient safety as perceived by nursing students: The findings of a cross-sectional study

BACKGROUND

Ensuring safety in health-care settings is provoking improvements both in education and clinical practice. However, the studies available have not offered to date information regarding knowledge and competence on patient safety (PS) developed by nursing students over their academic career. There is no documentation of the amount of close calls and/or adverse events that students may have witnessed and the degree of safety perceived in the attended clinical settings.

OBJECTIVES

To describe the perception of nursing students regarding their own knowledge and competence on PS and describe differences, if any, among students attending the first, second and third academic year.

DESIGN

A cross-sectional study design was undertaken in 2013.

PARTICIPANTS AND SETTING

A convenience sample of 621 nursing students of two bachelors nursing degrees located in two Italian universities, was the population target of the study. Students attending the first, second and third academic year, obtaining admission to the annual clinical competence examination, were eligible.

METHODS

The Italian version of the Health Professional Education in Patient Safety Survey (H-PEPSSIta) and open-ended questions was administered to the students after having obtained their informed written consent.

RESULTS

A total of 573 students (response rate 92.4%) participated. Around a quarter (28.8%) of students reported having experienced an adverse event or close call during their clinical experience. The settings where they learn were perceived as unsafe by 46.9% of students. PS knowledge and competence as perceived by students, was high (Median=4) in all factors and dimensions of the H-PEPSSIta tool. High PS knowledge and competence was reported by first-year students, moderate by second-year students and higher at the end of the third-year.

CONCLUSIONS

Faculties and health-care institutions offering clinical placements have to share the responsibility of well-prepared future nurses, working together to improve PS through dialogue when issues are identified by students.

Estimated cost savings from reducing errors in the preparation of sterile doses of medications

BACKGROUND

Preventing intravenous (IV) preparation errors will improve patient safety and reduce costs by an unknown amount.

OBJECTIVE

To estimate the financial benefit of robotic preparation of sterile medication doses compared to traditional manual preparation techniques.

METHODS

A probability pathway model based on published rates of errors in the preparation of sterile doses of medications was developed. Literature reports of adverse events were used to project the array of medical outcomes that might result from these errors. These parameters were used as inputs to a customized simulation model that generated a distribution of possible outcomes, their probability, and associated costs.

RESULTS

By varying the important parameters across ranges found in published studies, the simulation model produced a range of outcomes for all likely possibilities. Thus it provided a reliable projection of the errors avoided and the cost savings of an automated sterile preparation technology. The average of 1,000 simulations resulted in the prevention of 5,420 medication errors and associated savings of $288,350 per year. The simulation results can be narrowed to specific scenarios by fixing model parameters that are known and allowing the unknown parameters to range across values found in previously published studies.

CONCLUSIONS

The use of a robotic device can reduce health care costs by preventing errors that can cause adverse drug events.

Clinical pharmacist impact on care, length of stay, and cost in pediatric cystic fibrosis (CF) patients

BACKGROUND

Cystic fibrosis (CF) patients are often treated with aminoglycoside (AG) antibiotics during infective pulmonary exacerbations. Achieving pharmacokinetic and pharmacodynamic (PK/PD) targets to improve outcomes and counteract resistance is paramount.

PURPOSE

The primary objective was to compare the number of pediatric CF patients achieving AG PK/PD targets when a clinical pharmacist (CP) managed therapeutic drug monitoring (TDM) compared with usual care (UC).

METHODS

A retrospective cohort study was conducted on the records of 40 CF patients that received AGs and ≥2 serum samples between 1/2007 and 5/2009. Chi-square and Student's t-test were used to analyze nominal and continuous variables, respectively.

RESULTS

Twenty-nine patients with 52 courses of AGs were included the CP group, and 22 patients with 42 courses were included the UC group. Ninety-eight percent of patients in the CP group reached AG PK/PD targets compared with 71% in the UC group, P < 0.001. Patients in the CP group reached the AG PK/PD target in a mean of 1.9 ± 0.8 days compared with 4.8 ± 3.4 days in the UC group, P < 0.0001. The average LOS in the CP group was 9 ± 5 days compared with 12 ± 7.5 days in the UC group, P = 0.033. The mean number of levels per patient was 2.7 in the CP group compared with 5.2 (range of 2-20) in the UC group, P < 0.001. Resource utilization associated with drug levels, dosing adjustments and LOS were $26,549, $14,069, and $1,680,000 in the CP group as compared with $40,683, $27,812, and $1,940,000, respectively, in the UC group.

CONCLUSION

CP managed TDM resulted in a significantly higher percentage of pediatric CF patients achieving AG PK/PD targets 3 days sooner with an average LOS that was 3 days shorter. CP managed TDM resulted in significantly fewer dosage adjustments, drug levels, and cost associated with serum sampling, drug wastage, and LOS.

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study

The objective was to compare the characteristics of medication errors reported to 2 national error reporting systems by conducting a cross-sectional analysis of errors reported from adult intensive care units to the UK National Reporting and Learning System and the US MedMarx system. Outcome measures were error types, severity of patient harm, stage of medication process, and involved medications. The authors analyzed 2837 UK error reports and 56 368 US reports. Differences were observed between UK and US errors for wrong dose (44% vs 29%), omitted dose (8.6% vs 27%), and stage of medication process (prescribing: 14% vs 49%; administration: 71% vs 42%). Moderate/severe harm or death was reported in 4.9% of UK versus 3.4% of US errors. Gentamicin was cited in 7.4% of the UK versus 0.7% of the US reports (odds ratio = 9.25). There were differences in the types of errors reported and the medications most often involved. These differences warrant further examination.

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network

OBJECTIVE

Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system.

METHODS

A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed investigators' concerns about sharing confidential incident reports (IRs): (1) the ability to identify sites and (2) potential loss of peer review statute protection. Of the 22 Pediatric Emergency Care Applied Research Network sites, 19 received institutional approval to submit deidentified IRs to the data center. Incident reports were randomly assigned to independent review; discordance was resolved by consensus. Incident reports were categorized by type, subtype, severity, staff involved, and contributing factors.

RESULTS

A total of 3,106 IRs were submitted by 18 sites in the first year. Reporting rates ranged more than 50-fold from 0.12 to 6.13 per 1000 patients. Data were sufficient to determine type of error (90% of IRs), severity (79%), staff involved (82%), and contributing factors (82%). However, contributing factors were clearly identified in only 44% of IRs and required extrapolation by investigators in 38%. The most common incidents were related to laboratory specimens (25.5%), medication administration (19.3%), and process variance, such as delays in care (14.4%).

CONCLUSIONS

Incident reporting provides qualitative data concerning safety events. Perceived legal barriers to sharing confidential data can be addressed. Large variability in reporting rates and low rates of providing contributing factors suggest a need for standardization and improvement of safety event reporting.

[Patient safety: use of quality management to prevent medication errors in the hospital medication use cycle]

OBJECTIVES

To describe the medication errors in the medication use cycle in a general public hospital, and to identify intervention strategies in relation to the detection and prevention of these errors.

METHODS

Descriptive study with cross-sectional design. General public hospital of 190 beds, in Rosario (Argentina). Daily and systematic data collection of the circuit of use of medicines during May 2009. Once the errors were identified and classified, an interdisciplinary group sequentially applied different quality management tools to recognize and weigh causes, and propose solutions. (Flowchart, Cause Effect Diagram, Brainstorming, Nominal Group and Matrix Decision).

RESULTS

Information on 60 patients was retrieved during the study period, with 506 medication errors detected. The impact indicators showed the following values: 8.4 errors/patient and 88.6 errors/100 patients-day. From the causes identified, two were defined as relevant: "Double prescription" and "Lack of clear policy". Of the various solutions proposed, an intervention strategy was defined to include a differently designed form for "prescription/indication/administration" in the clinical history which could be updated daily, with a duplicate to Pharmacy for the distribution, as well as a Standard Operating Procedure to standardize this new way of working.

CONCLUSION

This work achieved, through quality management, the commitment of a team of health professionals to seek and make changes for patient safety, and to improve the quality of services provided by the hospital.

How are the costs of drug-related morbidity measured?: a systematic literature review

BACKGROUND

Drug-related morbidity has been associated with increased healthcare costs and has been suggested as one of the leading causes of death. Previous reviews have identified heterogeneity in research methods in studies measuring the cost of drug-related morbidity. To date, no attempt has been made to analyse different methods and cost sources used when estimating the costs of drug-related morbidity.

OBJECTIVE

The aim of this review was to evaluate and compare methods and data sources in cost estimates of drug-related morbidity.

METHODS

A literature search was conducted in three electronic databases (CINAHL, EMBASE and MEDLINE) to identify peer-reviewed articles written in English and published between January 1990 and November 2011. Articles were included if estimating the direct or indirect costs of drug-related morbidity based on clinical data from general patient groups. The general patient groups were defined as patients visiting, being admitted to, treated at or discharged from a general hospital, excluding studies from nursing homes or specialized hospitals. Study information was collected using a standardized data collection sheet. Studies were categorized according to the type of costs included in the cost analysis. Thereafter, the cost analyses of included studies were reviewed regarding viewpoint, costing methods and adjustments for timing of costs.

RESULTS

In total, 9569 articles were identified, of which 25 publications were included in this review, and four additional articles were identified from reference or citation lists of publications already included. Eighteen studies measured either the total or attributable costs of drug-related morbidity, while seven studies estimated the increased costs using matched controls or regression analyses. Six studies measured costs from a payer perspective, while the other 23 measured costs to the hospital. One study included costs resulting after discharge, and discounted future costs, while the remaining 28 studies measured costs during the initial admission only and involved no adjustment for timing of costs.

CONCLUSIONS

The data sources and costs measured in the included studies varied considerably in terms of perspectives and use of data sources. Even though there is a trend towards more studies estimating costs from the payer perspective, the identified studies still focused on costs resulting from patients attending hospital, therefore underestimating the cost of drug-related morbidity. There is thus a need for more research on the costs of drug-related morbidity to providers other than hospitals, and costs occurring outside of hospitals and after the initial care episode. Such studies require clear descriptions of how the costs of drug-related morbidity are measured, and should adhere to published guidelines for observational studies and economic evaluation studies.

[Prioritization of healthcare programs by pharmacy students from France and from Quebec, according to the perceived impact of a decentralized pharmacist]

INTRODUCTION

Healthcare decision makers need to establish priorities and their decisions must be justified. However, few data is available on the prioritization process of the healthcare programs that should benefit from decentralized pharmacists.

PATIENTS AND METHODS

The main objective was to prioritize healthcare programs according to the perceived impact of a decentralized pharmacist for outpatient and inpatient clienteles. The secondary objective was to compare the prioritization made by pharmacy students from two Quebec universities and from one French university. Two different approaches were developed (perceived impact according to three indicators and according to the global impact).

RESULTS

The majority of healthcare programs with a high evidence based literature quality score (5/6 outpatient programs and 5/8 inpatient programs) were highly prioritized by at least two out of three cohorts. The median rank that was attributed for each healthcare program was significantly different between the three cohorts for 8/17 (47%) of outpatient programs and for 10/18 (56%) of inpatient programs.

DISCUSSION

A higher rank was attributed to healthcare programs when the evidence based literature quality score was high. The prioritization was also influenced by the difference in pharmaceutical practice between France and Quebec (e.g. sterilization and medical devices in France).

CONCLUSIONS

This study presented two approaches for the prioritization of healthcare programs that should benefit from a decentralized pharmacist, according to students from France and from Quebec.

Impact of sample size on variation of adverse events and preventable adverse events: systematic review on epidemiology and contributing factors

OBJECTIVES

To perform a systematic review of the frequency of (preventable) adverse events (AE/PAE) and to analyse contributing factors, such as sample size, settings, type of events, terminology, methods of collecting data and characteristics of study populations.

REVIEW METHODS

Search of Medline and Embase from 1995 to 2007. Included were original papers with data on the frequency of AE or PAE, explicit definition of study population and information about methods of assessment. Results were included with percentages of patients having one or more AE/PAE. Extracted data enclosed contributing factors. Data were abstracted and analysed by two researchers independently.

RESULTS

156 studies in 152 publications met our inclusion criteria. 144/156 studies reported AE, 55 PAE (43 both). Sample sizes ranged from 60 to 8,493,876 patients (median: 1361 patients). The reported results for AE varied from 0.1% to 65.4%, and for PAE from 0.1% to 33.9%. Variation clearly decreased with increasing sample size. Estimates did not differ according to setting, type of event or terminology. In studies with fewer than 1000 patients, chart review prevailed, whereas surveys with more than 100,000 patients were based mainly on administrative data. No effect of patient characteristics was found.

CONCLUSIONS

The funnel-shaped distribution of AE and PAE rates with sample size is a probable consequence of variation and can be taken as an indirect indicator of study validity. A contributing factor may be the method of data assessment. Further research is needed to explain the results when analysing data by types of event or terminology.

An assessment of drug administration compliance in a university hospital centre

RATIONALE, AIMS AND OBJECTIVES

Ensuring the safety of the medication process is a major world health concern. Within this framework, a field study of compliance at various stages of the medication process in health care units was conducted. The objective of our study was to compare compliance at the moment of drug administration at the patient's bedside before and after implementing certain measures (self-study activities for the nursing staff, publication of the findings of the preliminary study and identification of priorities for action, among others).

METHODS

This is an observational study aimed at comparing compliance at various stages of the medication process in terms of dose verification, preparation and administration, on ward, before and after the implementation of corrective measures. Compliance was evaluated using an observational checklist that included 36 criteria. The evaluation was conducted on inpatients in nine health care units and the Emergency Care Unit of a university hospital centre. Compliance rates were calculated for each evaluated criterion separately and by category. The degree of significance and corresponding changes between 2007 and 2008 were also measured.

RESULTS

The compliance rate for all the applicable criteria used on the checklist showed a significant increase from 16% in 2007 to 28% in 2008. A significant increase was also observed in the compliance rates for drug verification (91% vs. 76%) and drug preparation on wards (50% vs. 23%), particularly with regard to entering drug names and a second identifier on the label.

CONCLUSIONS

Compliance rates at various separately evaluated stages in 2008 were relatively satisfactory. There is, however, room for improvement in total compliance. The introduction of simple tools and adapted communication strategies led to a sizeable improvement in the medication process at our facility.

The Rate and Costs Attributable to Intravenous Patient-Controlled Analgesia Errors

Purpose

To estimate the rates and costs of intravenous patient-controlled analgesia (IV PCA) errors from the hospital or integrated health system perspective.

Methods

This study used a cost-accounting methodology to estimate the costs attributable to IV PCA errors in the United States. Data for the study were obtained from the MEDMARX and Manufacturer and User Facility Device Experience (MAUDE) datasets, published literature, and expert opinions. MEDMARX is a voluntary, anonymous, medication-error-reporting database owned and operated by the United States Pharmacopeia. MAUDE is a mandatory, device-error-reporting database maintained by the US Food and Drug Administration. Levels of care rendered as a result of the IV PCA errors were estimated by applying clinical assumptions (validated by an expert advisory panel) to each of the 7 error consequences considered in this analysis. Variable and opportunity costs (2006 values) were considered, including medication, laboratory, lost revenue, and labor. The corresponding costs were applied to the error consequences to derive the estimated mean cost for each error cause. The numbers of errors documented in each dataset and the published literature were used to extrapolate the rate of IV PCA errors annually.

Results

The average cost per error event was $733 in the MEDMARX dataset and $552 in the MAUDE dataset. Harmful IV PCA errors were 120 to 250 times more costly than nonharmful errors. The annual error rates were estimated as 407 IV PCA-related errors and 17 device-related errors per 10,000 people within the United States. Conclusion: Analysis of 2 datasets, MEDMARX and MAUDE, revealed that IV PCA medication- and device-related errors are costly to hospitals and integrated health systems and represent a significant burden on the US health system. This study provided a novel approach to estimating the associated costs of undesired IV PCA-related events. Additional research is needed to validate the methodology (as applied to this area) and results.

Prescription errors in Brazilian hospitals: a multi-centre exploratory survey

In Brazil, millions of prescriptions do not follow the legal requirements necessary to guarantee the correct dispensing and administration of medication. This multi-centre exploratory study aimed to analyze the appropriateness of prescriptions at four Brazilian hospitals and to identify possible errors caused by inadequacies. The sample consisted of 864 prescriptions obtained at hospital medical clinics in January 2003. Data was collected by three nurse researchers during one week using a standard data sheet that included items about: the type of prescription; legibility; completeness; use of abbreviations; existence of changes and erasures. There were statistically significant differences between incomplete electronic prescriptions at hospital A, and handwritten ones from hospitals C (Ç2 = 12.703 and p < 0.001) and D (Ç2 = 14.074 and p < 0.001). Abbreviations were used in more than 80% of prescriptions at hospitals B, C and D. Changes were found in prescriptions at all hospitals, with higher levels at hospitals B (35.2%) and A (25.3%). This study identified a range of vulnerable points in the prescription phase of the medication system at the hospitals. Physicians, pharmacists and nurses should therefore jointly propose strategies to avoid these prescription errors.

Frequency, types, and potential clinical significance of medication-dispensing errors

INTRODUCTION AND OBJECTIVES

Many dispensing errors occur in the hospital, and these can endanger patients. The purpose of this study was to assess the rate of dispensing errors by a unit dose drug dispensing system, to categorize the most frequent types of errors, and to evaluate their potential clinical significance.

METHODS

A prospective study using a direct observation method to detect medication-dispensing errors was used. From March 2007 to April 2007, 'errors detected by pharmacists' and 'errors detected by nurses' were recorded under six categories: unauthorized drug, incorrect form of drug, improper dose, omission, incorrect time, and deteriorated drug errors. The potential clinical significance of the 'errors detected by nurses' was evaluated.

RESULTS

Among the 734 filled medication cassettes, 179 errors were detected corresponding to a total of 7249 correctly fulfilled and omitted unit doses. An overall error rate of 2.5% was found. Errors detected by pharmacists and nurses represented 155 (86.6%) and 24 (13.4%) of the 179 errors, respectively. The most frequent types of errors were improper dose (n = 57, 31.8%) and omission (n = 54, 30.2%). Nearly 45% of the 24 errors detected by nurses had the potential to cause a significant (n = 7, 29.2%) or serious (n = 4, 16.6%) adverse drug event.

CONCLUSIONS

Even if none of the errors reached the patients in this study, a 2.5% error rate indicates the need for improving the unit dose drug-dispensing system. Furthermore, it is almost certain that this study failed to detect some medication errors, further arguing for strategies to prevent their recurrence.

Waste in the U.S. Health care system: a conceptual framework

CONTEXT

Health care costs in the United States are much higher than those in industrial countries with similar or better health system performance. Wasteful spending has many undesirable consequences that could be alleviated through waste reduction. This article proposes a conceptual framework to guide researchers and policymakers in evaluating waste, implementing waste-reduction strategies, and reducing the burden of unnecessary health care spending.

METHODS

This article divides health care waste into administrative, operational, and clinical waste and provides an overview of each. It explains how researchers have used both high-level and sector- or procedure-specific comparisons to quantify such waste, and it discusses examples and challenges in both waste measurement and waste reduction.

FINDINGS

Waste is caused by factors such as health insurance and medical uncertainties that encourage the production of inefficient and low-value services. Various efforts to reduce such waste have encountered challenges, such as the high costs of initial investment, unintended administrative complexities, and trade-offs among patients', payers', and providers' interests. While categorizing waste may help identify and measure general types and sources of waste, successful reduction strategies must integrate the administrative, operational, and clinical components of care, and proceed by identifying goals, changing systemic incentives, and making specific process improvements.

CONCLUSIONS

Classifying, identifying, and measuring waste elucidate its causes, clarify systemic goals, and specify potential health care reforms that-by improving the market for health insurance and health care-will generate incentives for better efficiency and thus ultimately decrease waste in the U.S. health care system.

Just what the doctor ordered. Review of the evidence of the impact of computerized physician order entry system on medication errors

OBJECTIVE

To examine the association between computerization of physician orders and prescribing medication errors. Data Sources. Studies published in English language were identified through MEDLINE (1990 through December 2005), Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles. Of 252 identified in the search, 12 (4.8 percent) original investigations that compared rates of prescribing medication errors with handwritten and computerized physician orders were included.

DATA COLLECTION

Information on study design, participant characteristics, clinical settings, and outcomes rates were abstracted independently by two investigators using a standardized protocol.

PRINCIPAL FINDINGS

Compared with handwritten orders, 80 percent of studies (8/10 studies) reported a significant reduction in total prescribing errors, 43 percent in dosing errors (3/7 studies), and 37.5 percent in adverse drug events (3/8 studies). The use of computerized orders was associated with a 66 percent reduction in total prescribing errors in adults (odds ratio [OR]=0.34; 95 percent confidence interval [CI] 0.22-0.52) and a positive tendency in children (p for interaction=.028). The benefit of computerized orders was larger when the rate of errors was more than 12 percent with handwritten orders (p for interaction=.022). Significant heterogeneity in the results compromised pooled relative risks. One randomized controlled intervention demonstrated the greatest benefits of computerized orders on total prescribing errors (OR=0.02, 95 percent CI 0.01-0.02) and dosing errors (OR=0.28; 95 percent CI 0.15-0.52) with 775 avoided prescribing errors (95 percent CI 752-811) per 1,000 orders in a pediatric hospital.

CONCLUSIONS

Computerization of physicians' orders shows great promise. It will be more effective when linked to other computerized systems to detect and prevent prescribing errors.

Raising the awareness of inpatient nursing staff about medication errors

OBJECTIVE

The study objective was to design and implement an educational programme to raise the awareness of in-patient nursing staff about medication errors and other medication-related safety issues.

METHOD

A sample of in-patient nursing staff in Al Ain hospital (n = 370) was included in the study and completed a self-reported questionnaire about medication errors. A structured program was developed and used by the clinical pharmacists to identify the nursing knowledge on medication errors and other medication-related safety issues. The program consisted of a pre/post self-reported questionnaire, a training service, educational material, successive presentations and handouts. The self-reported questionnaire included twenty closed questions asking nurses opinions about medication errors. A training program on medication safety (Med Safe tool) was carried out by [clinical pharmacy team (n = 2) and quality coordinator nurse (n = 1)], for each group of 10 nurses. Main outcome measure The study outcomes were the change in mean scores pre and post intervention.

RESULTS

Findings revealed differences in the knowledge of nurses about the causes and reporting of medication errors. There were statistically significant differences in responses across the participant's years of experience and the current clinical working area. The participant's responses improved significantly [57.4% +/- 8.2, (95%CI: 56.6-58.2) vs. 68.9 +/- 10.3, (95%CI: 67.8-69.9); P < 0.05] pre and post questionnaire respectively.

CONCLUSIONS

The clinical pharmacist's structured program has improved knowledge of the in-patient nursing staff in terms of raising their awareness about medication errors.

A Medication Safety Education Program to Reduce the Risk of Harm Caused by Medication Errors

A medication safety education program was developed and implemented to reduce the harm caused to patients by medication errors, specifically errors related to the intravenous infusion of high-alert medications. Participants were required to complete two 30-minute computer modules focusing on medication safety. Changes in the climate of safety, nurses' knowledge and behavior, and the number of infusion pump alerts and reported medication errors were evaluated both before and after completion of the education program. A statistically significant change in knowledge regarding medication errors occurred, but there was no change in the climate of safety scores, the use of behaviors advocated in the medication safety education program to improve medication infusion safety, the number of infusion pump alerts, or the number of reported errors. It was concluded that there was a need for strong administrative support and follow-up to foster changes in behavior, which can lead to a reduction in harm caused by medication errors.

Pharmacist workload and pharmacy characteristics associated with the dispensing of potentially clinically important drug-drug interactions

BACKGROUND

Drug-drug interactions (DDIs) are preventable medical errors, yet exposure to DDIs continues despite systems that are designed to prevent such exposures. The purpose of this study was to examine pharmacy characteristics that may be associated with dispensed potential DDIs.

METHODS

This study combined survey data from community pharmacies in 18 metropolitan statistical areas with pharmacy claims submitted to 4 pharmacy benefit managers (PBMs) over a 3-month period from January 1, 2003 to March 31, 2003. Pharmacy characteristics of interest included prescription volume, the number of full-time equivalent pharmacists and pharmacy staff, computer software programs, and the ability to modify those programs with respect to DDI alerts, the use of technologies to assist in receiving, filling and dispensing medication orders, and prescription volume. The dependent variable in this study was the rate of dispensed medications that may interact.

RESULTS

A total of 672 pharmacies were included in the analysis. On average (+/-SD), the respondents filled 1375 +/- 691 prescriptions per week, submitted 17,948 +/- 23,889 pharmacy claims to the participating PBMs, had 1.2 +/- 0.3 full-time equivalent pharmacists per hour open, and 545 (81%) were affiliated with a chain drug store organization. Factors significantly related to an increased risk of dispensing a potential DDI included pharmacist workload (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.028-1.048), pharmacy staffing (OR 1.10; 95% CI: 1.09-1.11), and various technologies (eg, sophisticated telephone systems, internet receipt of orders, and refill requests) that assist with order processing, and the ability to modify DDI alert-screening sensitivity and detailed pharmacological information about DDIs.

CONCLUSIONS

This study found that there was an increase in the risk of dispensing a potential DDI with higher pharmacist and pharmacy workload, use of specific automation, and dispensing software programs providing alerts and clinical information.

Clinical Pharmacy Services, Pharmacy Staffing, and Hospital Mortality Rates

OBJECTIVE

To determine if hospital-based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates.

METHODS

A database was constructed from 1998 MedPAR, American Hospital Association's Annual Survey of Hospitals, and National Clinical Pharmacy Services databases, consisting of data from 2,836,991 patients in 885 hospitals. Data from hospitals that had 14 clinical pharmacy services were compared with data from hospitals that did not have these services; levels of hospital pharmacist staffing were also compared. A multiple regression analysis, controlling for severity of illness, was used.

RESULTS

Seven clinical pharmacy services were associated with reduced mortality rates: pharmacist-provided drug use evaluation (4491 reduced deaths, p=0.016), pharmacist-provided in-service education (10,660 reduced deaths, p=0.037), pharmacist-provided adverse drug reaction management (14,518 reduced deaths, p=0.012), pharmacist-provided drug protocol management (18,401 reduced deaths, p=0.017), pharmacist participation on the cardiopulmonary resuscitation team (12,880 reduced deaths, p=0.009), pharmacist participation on medical rounds (11,093 reduced deaths, p=0.021), and pharmacist-provided admission drug histories (3988 reduced deaths, p=0.001). Two staffing variables, number of pharmacy administrators/100 occupied beds (p=0.037) and number of clinical pharmacists/100 occupied beds (p=0.023), were also associated with reduced mortality rates.

CONCLUSION

The number of clinical pharmacy services and staffing variables associated with reduced mortality rates increased from two in 1989 to nine in 1998. The impact of clinical pharmacy on mortality rates mandates consideration of a core set of clinical pharmacy services to be offered in United States hospitals. These results have important implications for health care in general, as well as for our profession and discipline.

Medication errors in children

Medication error is a major source of iatrogenic injuries in children. Dosing errors are the most common type of medication errors in pediatrics. Sicker patients in intensive care units and emergency departments are more often harmed by such errors. Strategies that have been found to be effective in reducing medication errors include the use of computerized physician order entry systems, preprinted order forms, and color-coded systems. Adopting the "systems approach" to medication errors is crucial to every health system where practitioners seek to enhance patient safety.

A pharmacoepidemiologic study of drug interactions in a Brazilian teaching hospital

PURPOSE

Although drug-drug interactions constitute only a small proportion of adverse drug reactions, they are often predictable and therefore avoidable or manageable. There are few studies on drug-drug interactions from Brazil. This study aimed to assess the frequency of drug-drug interactions in prescriptions and their potential clinical significance in patients of a Brazilian teaching hospital.

METHODS

From January to April 2004, a sample of 1785 drug prescriptions was drawn from a total of 11,250. Drug-drug interactions were identified by using Micromedex DrugReax System. Patients'records with major drug-drug interactions were reviewed by a pharmacist and a medical doctor looking for signs, symptoms, and lab tests that could indicate adverse drug reactions due to such interactions.

RESULTS

From the 1785 prescriptions examined, 1089 (61%) were from the male adult ward. Patients' average age was 52.7 years (SD = 18.9; range, 12-98). The median number of drugs in each prescription was 7 (range, 2-26). At least 1 drug-drug interactions was present in 887 (49.7%) prescriptions. Regarding the severity of the clinical result, the interactions were classified as minor (20; 2.3%), moderate (184; 20.7%), major (30; 3.4%), and undetermined because of an incidence of more than 1 interaction in a single patient (653; 73.6%). From the 30 patients with major interactions, 17 (56.7%) presented adverse drug reactions induced by exposure to a major drug-drug interaction.

CONCLUSIONS

Patients did suffer adverse drug reactions from major drug-drug interactions. Many physicians may be unaware of drug-drug interactions. Education, computerized prescribing systems and drug information, collaborative drug selection, and pharmaceutical care are strongly encouraged for physicians and pharmacists.

Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals

Adverse drug reactions (ADRs) were examined in 1,960,059 hospitalized Medicare patients in 584 United States hospitals in 1998. A database was constructed from the MedPAR database and the National Clinical Pharmacy Services survey. The 584 hospitals were selected because they provided specific information on 14 clinical pharmacy services and on pharmacy staffing; they also had functional ADR reporting systems. The study population consisted of 35,193 Medicare patients who experienced an ADR (rate of 1.8%). Of the 14 clinical pharmacy services, 12 were associated with reduced ADR rates. The most significant reductions occurred in hospitals offering pharmacist-provided admission drug histories (odds ratio [OR] 1.864, 95% confidence interval [CI] 1.765-1.968), drug protocol management (OR 1.365, 95% CI 1.335-1.395), and ADR management (OR 1.360, 95% CI 1.328-1.392). Multivariate analysis, performed to further evaluate these findings, showed that nine variables were associated with ADR rate: pharmacist-provided in-service education (slope -0.469, p=0.018), drug information (slope -0.488, p=0.005), ADR management (slope -0.424, p=0.021), drug protocol management (slope -0.732, p=0.002), participation on the total parenteral nutrition team (slope 0.384, p=0.04), participation on the cardiopulmonary resuscitation team (slope -0.506, p=0.008), medical round participation (slope -0.422, p=0.037), admission drug histories (slope -0.712, p=0.008), and increased clinical pharmacist staffing (slope -4.345, p=0.009). As clinical pharmacist staffing increased from the 20th to the 100th percentile (from 0.93+/-0.77/100 to 5.16+/-4.11/100 occupied beds), ADRs decreased by 47.88%. In hospitals without pharmacist-provided ADR management, the following increases were noted: mean number of ADRs/100 admissions by 34.90% (OR 1.360, 95% CI 1.328-1.392), length of stay 13.64% (Mann-Whitney U test [U]=11047367, p=0.017), death rate 53.64% (OR 1.574, 95% CI 1.423-1.731), total Medicare charges 6.88% (U=111298871, p=0.018), and drug charges 8.16% (U=108979074, p<0.001). Patients in hospitals without pharmacist-provided ADR management had an excess of 4266 ADRs, 443 deaths, 85,554 patient-days, $11,745,342 in total Medicare charges, and $1,857,744 in drug charges. The implications of these findings are significant for our health care system, especially considering that the study population represented 15.55% of 12,261,737 Medicare patients and 5.71% of the 34,345,436 patients admitted to all U.S. hospitals.

Clinical and Economic Outcomes of Pharmacist-Managed Antiepileptic Drug Therapy

This study explores the associations between pharmacist-managed antiepileptic drug therapy in hospitalized Medicare patients and diagnoses indicating the need for these drugs. It also explores the following major heath care outcomes: death rate, hospital length of stay (LOS), Medicare charges, drug charges, laboratory charges, complications, and adverse drug reactions. Data were drawn from the 1998 MedPAR and 1998 National Clinical Pharmacy Services databases. Pharmacist-managed antiepileptic drug therapy was evaluated in a study population of 9380 Medicare patients with diagnosed epilepsy or seizure disorders treated in 794 United States hospitals. This population was derived from the 38,311 hospitalized Medicare patients with epilepsy or seizure disorders (MedPAR). In hospitals without pharmacist-managed antiepileptic drug therapy, death rates were 120.61% higher, with 374 excess deaths (chi(2)=5.983, df=1, p=0.014, odds ratio [OR]=1.553, 95% confidence interval [CI] 1.102-2.189). Hospital LOS was 14.68% higher, with 8069 patient-days (Mann-Whitney U test [U]=3833132, p=0.0009); total Medicare charges were 11.19% higher, with 14,372,550 dollars in excess total charges (U=3644199, p=0.0003); per-patient drug charges were $115 +/- $92 higher (p=NS); laboratory charges were 32.24% higher, with 5,664,970 dollars in excess charges; and aspiration pneumonia rate was 54.61% higher (chi(2)=5.848, df=1, p=0.015, OR=1.233, 95% CI 1.081-1.901). Although the frequencies of other complications and adverse effects were higher, these differences were not statistically significant compared with hospitals with pharmacist-managed antiepileptic drug therapy. Clinical and economic outcomes were improved among hospitalized Medicare patients whose antiepileptic drug therapy was managed by pharmacists.

Prescription errors in psychiatry - a multi-centre study

Medication errors are an important cause of patient morbidity and mortality, of which there have been few reports in psychiatry, especially in the UK. Our aim was to examine the nature, frequency and potential severity of prescribing errors in UK mental health units in a prospective, 1 week survey of errors detected by pharmacy staff in nine NHS trusts. Pharmacists checked 22036 prescription items. In total, 523 errors meeting the study definition were detected (2.4% of prescription items checked). Prescription writing errors (77.4%) were most common, while decision-making errors accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been administered before the error was detected. Most errors were of doubtful or minor importance but 22 (4.3%) were deemed likely to result in serious adverse effects or death. The error detection rate varied fourfold between trusts. Prescribing errors are fairly common in psychiatry. A small proportion of errors have the potential for serious harm. Pharmacy staff have an important role to play in their management.

A spike in fatal medication errors at the beginning of each month

At the beginning of each month, there is a spike in government payments to individuals, resulting in a beginning-of-the-month spike in purchases of prescription drugs and in increased pharmacy workloads. Studies suggest that pharmacy error rates increase with increased workloads. These facts raise an important and previously unanswered question: is there a spike in fatal medication errors at the beginning of each month? We examined all United States death certificates from 1979-2000 (> 47,000,000 deaths) and showed that medication error deaths for which the decedent was dead on arrival or died in the emergency room or as an outpatient spiked by 25% above normal at the beginning of each month. This beginning-of-the-month spike (25% +/- 4%) was larger than for any other major cause of death. The beginning-of-the-month spike did not vary by socioeconomic status and was not larger for substance abusers than for others. Five explanations for the findings were tested. Evidence suggested that the spike in medication error deaths cannot be solely attributed to a spike in the consumption of alcohol or drugs. An increase in pharmacy error rates might play a role.

Validation pharmaceutique des prescriptions hospitalières

BACKGROUND

Analysis and validation of hospital prescriptions by the pharmacy department, although mandatory since 1991, appears relatively uncommon. Little is known of the nature and frequency of the actions taken by clinical pharmacists during this process.

OBJECTIVE

To describe the nature and frequency of pharmaceutical interventions in a large university hospital.

METHODS

We reviewed interventions during the pharmaceutical analysis of prescriptions in a surgical ward, a general medical ward and a short-stay hospital unit over a 5-year period.

RESULTS

Pharmacists took some type of action in 1438 of the 13,760 prescriptions analyzed (10.4%). Drug interactions accounted for 30.9% of the interventions; 20.2% concerned dose adaptation in cases of renal insufficiency; 13.8% proposed a change from injectable to oral drugs; and 4.1% concerned the physicochemical incompatibility of the simultaneous administration of two drugs through the same infusion line. Drug interactions most frequently involved oral fluoroquinolones and anticoagulants. Dose adaptation was suggested most often for amoxicillin, buflomedil, ofloxacin and allopurinol, while the pharmacists most often proposed changing mixtures of multivitamins, omeprazole, imidazole derivatives and fluoroquinolones from parenteral to oral administration. Physicochemical incompatibility was most frequently associated with furosemide or nicardipine and with antibiotics.

CONCLUSION

The analysis of prescriptions by a pharmacist is useful for medical teams: it helps to modify common attitudes towards prescribing drugs and contributes to their appropriate use and to the prevention of adverse events.

Medication Errors in an Internal Medicine Department. Evaluation of a Computerized Prescription System

OBJECTIVE

Evaluation of a computerized physician order entry in an Internal Medicine Department, with a unit-dose distribution system.

SETTING

Pharmacy Department, Internal Medicine Department. S. Francisco Xavier Hospital, Lisbon, Portugal.

METHOD

This study was carried out in December 2001 and January 2002. After two years experience of the CPOE system, medication errors were evaluated prospectively, in an internal medical department of a 360-bed academic hospital. Data were collected once a week. Pharmacists reviewed all medical prescriptions as part of their routine work. Medication errors detected were recorded on a data collection form with a design based on the types of errors as defined by the American Society of Hospital Pharmacists (ASHP). Completed forms were reviewed and medication errors were classed according to ASHP guidelines.

RESULTS

A total of 2268 orders were monitored (162 patients). In these orders, 73 medication errors (22.4% of the patients) were detected and documented (59 prescribing errors and 14 monitoring errors). The most common prescribing errors were deficiencies related to the right class but wrong drug (28.3%): omeprazole vs. ranitidine/sucralfate in stress ulcer prophylaxis; incorrect dose (30%) and unclear orders (13.3%). Errors related to incorrect frequency of administration (5%); maintenance of IV route (5%); duplicated drug therapy (11.7%); drug interactions (1.7%) and length of therapy (3.3%) were also detected. The 14 monitoring errors detected were failures to review a prescribed regimen for appropriateness and detection of problems.

CONCLUSIONS

Computerized prescription order entry has demonstrated effectiveness in eliminating medication errors related to transcribing and patient identification. Nevertheless, medication errors related to prescription and monitoring still occur. The use of clinical decision support systems and pharmacist involvement is vital to achieve maximum medication safety and reduce medication error rates.

Managed Care and Patient Safety

OBJECTIVE

Patient safety practices have primarily focused on providers, such as hospitals and ambulatory or long-term care. Based on the premise that most medical errors and patient safety problems arise from system issues, and that managed care constitutes the largest, most integrated system in health care, the authors examine the role of managed care in making patient care safer.

STUDY DESIGN

Review of the literature and analysis of the role of managed care in patient safety.

RESULTS

Authors find that although much has been written regarding managed care and quality, there is little research on managed care's relationship to patient safety. Research shows that managed care is not significantly different from indemnity insurance in terms of quality of care. However, managed care contracting, reimbursement, and management practices result in health care utilization changes that could pose potential risks for patient safety. Although managed care may pose possible risks to patient safety, practices can be monitored and adjusted to maintain quality and safety. At the same time, managed care provides opportunities for promoting patient safety at an integrated system level. Managed care organizations are in a unique position to influence patient safety by using safety strategies in selective contracting, financial incentives for performance, quality improvement programs, consumer education, and management and integration of care delivery. Our literature review reveals that health plans are starting to implement some of these strategies, but the practice is not widespread.

CONCLUSIONS

Authors conclude with a framework and recommendations for patient safety.