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Pennsylvania Hospital Data Shows Increased Likelihood of Medication Errors When In-House Pharmacy is Closed

March 1, 2012

Over 500 medication error reports imply an event occurred while the pharmacy department was closed

HARRISBURG, Pa., March 1, 2012 /PRNewswire-USNewswire/ — Between June 2004 and September 2010, Pennsylvania hospitals submitted 519 medication error reports to the Patient Safety Authority that implied an event occurred while the pharmacy department was closed, according to information published in the March Pennsylvania Patient Safety Advisory released today.

On-site 24-hour pharmaceutical services can provide a more secure drug storage and distribution system. It also reduces the need for night cabinets, non-pharmacist access to the pharmacy and access to medications stored in automated dispensing cabinets (ADCs) without prior order review by a pharmacist. Without safeguards in place, medication errors can occur, some with tragic outcomes, especially if non-pharmacists have complete access to the pharmacy after hours.

The most common types of medication errors reported by facilities when the pharmacy was closed include wrong-drug events (30.4%), drug omissions (28.9%) and prescription or refill delays (11%). According to the data, the incorrect drug was retrieved from an automated dispensing cabinet or night cabinet in 82% of 130 wrong-drug events.

“Eighty-seven percent of the events reached the patient, but only two resulted in harm significant enough to require additional treatment,” Michael J. Gaunt, PharmD, Senior Patient Safety Analyst for the Pennsylvania Patient Safety Authority said. “However, facilities should heed the warnings these near-miss events have given them to identify system-based causes of the medication errors that took place because the on-site pharmacy services were not available.”

Gaunt added that of the top 10 medications involved in the events, four were high-alert medications, or drugs that have an increased risk of causing significant patient harm when used in error.

“Further, more than sixty-two percent of events that originated in the prescribing node of the medication-use process involved a patient that was prescribed a medication to which he or she had a documented allergy,” Gaunt said. “Only one documented allergy was caught before reaching the patient. Ninety-five percent of these events reached the patient, with one requiring additional treatment.”

Gaunt said that while an ideal solution is to establish an on-site 24-hour pharmaceutical service, there are other options that can decrease the likelihood of a medication error.

“Off-site pharmacy order entry services can provide a viable option for those facilities that cannot establish a 24-hour on-site service,” Gaunt said. “There are also many medication access and storage risk-reduction strategies that can be employed to help prevent these types of errors as well.”

For more information on the risk reduction strategies for medication errors when the pharmacy is closed, go to the Advisory article “Medication Errors: When Pharmacy is Closed” on the Authority’s website under Patient Safety Advisories March 2012.

The Authority’s 2012 March Advisory also contains other clinical articles with strategies and educational toolkits to improve patient safety. Highlights include:

  • Pennsylvania: On the CUSP of Measuring Infection Prevention Culture: A study done by the Patient Safety Authority shows Pennsylvania hospitals that participated in a project to positively change safety culture at the unit level reduced central venous catheter use by eight percent. The complete study and detailed research are discussed in this article.
  • Violence Prevention Training for Emergency Department Staff: A comprehensive violence prevention program is necessary to promote a safe environment for patient care in the emergency department. The Pennsylvania Patient Safety Authority surveyed violence protection practices in Pennsylvania acute care hospitals and identified gaps for improvement. Strategies to close the gaps are discussed in this article.
  • Colonoscopy-Associated Perforation: Systematic Review and Meta-Analysis of Incidence and Risk Factors: In this article, using meta-analysis and a qualitative literature review, analysts systematically assessed the incidence of and risk factors for colonoscopy-associated perforation. Analysts included English-language full-length reports published between 1/1/1990 and 6/16/2010 that assessed patients undergoing colonoscopy and were identified in searches of 12 electronic databases, bibliographies and gray literature. The results of this research and suggestions for further study in this area are discussed.
  • Ambulatory Surgical Facility Survey Report: The Authority developed and administered a statewide needs assessment survey to inform an ambulatory surgical facility collaboration that will address same-day cancellations and transfers. The survey examined presurgical screening and assessment processes and cancellation and transfer information. The results provide insights into how the history and physical information is gathered, who the primary contact person is for preoperative screening and instructions, the reasons and rates for same-day cancellations and transfers and the number of facilities that have implemented an electronic health record.
  • Quarterly Update on Preventing Wrong-Site Surgery: This quarterly update discusses five issues: the direction of the Patient Safety Authority project to prevent wrong-site surgery; estimates of the incidence of wrong-site anesthetic blocks and ureteral stent insertions; informative near-miss reports; preventing misinformation from the surgeon’s office; and the relationship between wrong-site surgery and the operating room (OR) culture of safety. Two additional educational toolkits designed for surgeons’ offices to help prevent wrong-site surgery are also discussed.

For the complete 2012 March Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.

SOURCE Pennsylvania Patient Safety Authority


Source: PR Newswire