Pharmacist intervention on prescribing errors: Use of a standardized approach in the inpatient setting

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The objective of this study was to implement a standardized process across health systems to determine the prevalence and clinical relevance of prescribing errors intercepted by pharmacists. Methods This prospective, multicenter, observational study was conducted across 11 hospitals. Pharmacist-intercepted prescribing errors were collected during inpatient order verification over 6 consecutive weeks utilizing a standardized documentation process. The potential harm of each error was evaluated using a modified National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index with physician validation, and errors were stratified into those with potentially low, serious, or life-threatening harm. Endpoints included the median error rate per 1,000 patient days, error type, and potential harm with correlating cost avoidance. Results Pharmacists intervened on 7,187 errors, resulting in a mean error rate of 39 errors per 1,000 patient days. Among the errors, 46.6% (n = 3,349) were determined to have potentially serious consequences and 2.4% (n = 175) could have been life-threatening if not intercepted. This equates to $874,000 in avoided cost. The top 3 error types occurring with the highest frequency were "wrong dose/rate/frequency” (n = 2,298, 32.0%), “duplicate therapy” (n = 1,431, 19.9%), and "wrong timing” (n = 960, 13.4%). “Wrong dose/rate/frequency” (n = 49, 28%), “duplicate therapy” (n = 26, 14.9%), and “drug-disease interaction” (n = 24, 13.7%) errors occurred with the highest frequency among errors with potential for life-threatening harm. “Wrong dose/rate/frequency” (n = 1,028, 30.7%), “wrong timing” (n = 573, 17.1%), and “duplicate therapy” (n = 482, 14.4%) errors occurred with the highest frequency among errors with potentially serious harm. Conclusion Documentation of pharmacist intervention on prescribing errors via a standardized process creates a platform for multicenter analysis of prescribing error trends and an opportunity for development of system-wide solutions to reduce potential harm from prescribing errors.

Medication incidents and pharmacist interventions in relation to directly acting oral anticoagulants in hospital settings: evaluation using Reason’s Accident Causation Theory

BackgroundDirect oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However DOACs medication incidents are known to be common.ObjectiveTo assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in secondary care settings.SettingA large University tertiary academic hospital in the West Midlands of England.MethodsMedication incident data from the incident reporting system (48-months period) and pharmacist interventions data from the prescribing system (26-month period) were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data was thematically analysed.Main outcome measure(a) Frequency, type and potential causality of DOACs incidents, (b) Nature of pharmacists’ interventions.ResultsA total of 812 DOACs reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%,n = 33) followed by wrong drug (16.1%,n = 20) and wrong dose/strength (11.3%,n = 14). A high majority (89.5%,n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. The majority of (38.1%,n = 262) the pharmacist interventions were related to pharmacological strategy (i.e., drug or dose changes or discontinuation). Impaired renal function was the most common reason for dose adjustments.ConclusionPrescribers’ active failure rather than system errors (i.e. latent failures) are contributing to DOACs incidents. Rreinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.

Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

An assessment of parents’ knowledge and awareness regarding paracetamol use in children: a cross-sectional study from Palestine

Background Paracetamol, also known as acetaminophen, is one of the most common antipyretic and analgesic over-the-counter (OTC) medicines administered to children due to its efficacy, safety, and availability in many pharmaceutical forms, including suppositories, syrup, and drops. Parents frequently administer the wrong dose of paracetamol by mistake for their children, as reported by many previous studies. We aimed in this study to assess parents’ knowledge, attitudes, and practice regarding paracetamol dosing and toxicity, as well as their awareness regarding paracetamol-containing products. Methods This was a cross-sectional study that targeted parents of children seeking healthcare services at primary health care centers in the Nablus area in the West Bank, Palestine. We used questionnaire-based interviews with parents for data collection. Results A total of 300 parents were included in the study. Most of the caregivers surveyed were (87%) females (mothers). About half the parents (50.9%) reported previously using paracetamol as an antipyretic in children under the age of six. A quarter (25.4%) preferred the syrup forms, while 33.8% preferred the suppository dosage form. Medical personnel was the primary source of information for half the caregivers (51.2%). The mean knowledge score about paracetamol was 2.1 (SD = 1.4) out of 6, and the median was 2.0 with an interquartile range of 1.0–3.0. Two hundred seventy-four (95.5%) of the participants scored less than 80% and were considered to have insufficient knowledge. Only 50.9% of parents recognized that paracetamol overdose could result in serious harm. Conclusions We found a serious lack of knowledge regarding paracetamol dosing, administration, and potential toxicity among Palestinian parents. We recommend raising awareness regarding this problem among healthcare providers and authorities and working on plans that aim to provide caregivers with accurate and adequate information on dosing, formulation, side effects, and other aspects of paracetamol use, as well as developing effective educational plans targeting healthcare providers, as well as the public.

Community pharmacists’ involvement in ensuring patient safety

Burden of injuries to patients from adverse events is one of the top 10 causes of death and disability in the world; medication errors are a leading cause of injury. Most adverse events can be avoided. The objective of this work was to study involvement of community pharmacy professionals in ensuring patient safety in Armenia. Community pharmacists and technicians from all the regions of Armenia were asked to complete previously designed questionnaire. 353 professionals completed self-administered questionnaire. Data were analysed with SPSS statistical software, version 22.0. 87.8% of respondents reported that they observe prescribing errors when evaluating prescription at pharmacy. 69.4% of them indicate that the main error is wrong dose; 32.3% pointed medicines interactions; 32.0% - contraindications. Number of professionals from Yerevan, who indicated wrong dose, is higher than number of those from other regions (p < 0.001). Only 5.1% of participants register errors at pharmacy. 83.0% of pharmacy staff reported they always or often evaluate therapeutic aspects of prescriptions. 42.2% of respondents noted that, when patient is pressing, they never dispense a medicine without being sure that it is safe for patient; 27.5% do it very rarely. 76.8% of responders are sure their services ensure safe use of medicines by patients. 26.1% of pharmacy staff reported having SOPs at their pharmacy; 80.3% are interesting in introducing this strategy. Various prescription errors are observed by community pharmacists; however they are mainly not registered (there is no such requirement). In some cases prescriptions are not evaluated at community pharmacies. Approval of new standards for pharmacy practice seems to be beneficial. Recommendations are drafted for submitting to Ministry of Health. Key messages Involvement of pharmacy professionals in ensuring patient safety have to be increased. There is need for changes in pharmacy practice regulation leading to safer use of medicines by patients.

SP2 Management of ethylene glycol poisoning in an adolescent: a clinical pearl

Situation16 year old girl admitted with suspected ingestion of ethylene glycol. She was treated with fomepizole and continuous renal replacement therapy (CRRT).How the Pharmacy Team ContributedEthanol was prescribed until fomepizole arrived. The volume of ethanol to be administered was calculated wrongly by the consultant due to confusion about the available strength. The Paediatric Intensive Care Unit (PICU) pharmacist intervened and the correct dosage information was given.PICU pharmacist used Toxbase to determine the correct treatment of ethylene glycol poisoning and advised on dosing regime, including adjustment due to CRRT. The pharmacist facilitated prescribing on the electronic system (added drug to system, set up administration instructions and assisted with prescribing – pharmacist was not an Independent Prescriber). This allowed medical staff to concentrate on resuscitation, monitoring cardiac function, inserting intravenous lines and obtaining access for CRRT.The PICU pharmacist and pharmacy technician co-ordinated initial supply of fomepizole. Fomepizole is usually ordered directly from the manufacturer during office hours. The patient presented in the early evening so further supply had to be obtained from a hospital hundreds of miles away after referring to the Rarely Used Medicines list. Pharmacist contacted appropriate on-call pharmacist and arranged for transfer of medicines via courier. Pharmacy technician arranged for further supply form the manufacturer the following day.Pharmacy technician arranged supply of additional dialysis fluids for CRRT due to the higher than usual administration rate.Without contribution from the pharmacy team the patient is likely to have been given the wrong dose of ethanol and fomepizole, and there would have been delay in initiation of treatment followed by an interruption, as it was wrongly assumed that it was kept as stock in the adjoining ‘adult hospital’ and subsequent supply from a local hospital would not have been sought by ward staff until original supply ran out.OutcomeEthylene glycol poisoning was confirmed on laboratory testing. Levels of ethylene glycol fell steadily over 36 hours, allowing CRRT and fomepizole to stop. Patient was discharged from PICU after 48 hours with no apparent long-lasting effects, but was referred to various specialities including renal, gastroenterology and psychology.Patient and family denied knowledge of intentional or accidental ingestion. Police investigation was inconclusive.Lessons to be LearnedLarger supplies of fomepizole are now kept in stock within Health Board. Supplies were missing from emergency cupboards when stock was needed, despite being on stock lists, necessitating courier fees to transfer stock from elsewhere. Procedures reviewed to ensure that stock is available in emergency cupboards at all times.This patient demonstrated that current (target) stock levels of fomepizole were inadequate for providing treatment during CRRT as the required doses are substantially higher (administered every four hours rather than every twelve hours) and would have lasted less than 12 hours for this average sized teenager. National Rarely Used Medicines list was updated to reflect actual stock levels and other hospitals increased their stockholding due to the realisation that existing stock was inadequate and that further supplies were hard to obtain out of working hours.

Twelve-Month Review of Infusion Pump Near-Miss Medication and Dose Selection Errors and User-Initiated “Good Save” Corrections: Retrospective Study

Background There is a paucity of quantitative evidence in the current literature on the incidence of wrong medication and wrong dose administration of intravenous medications by clinicians. The difficulties of obtaining reliable data are related to the fact that at this stage of the medication administration chain, detection of errors is extremely difficult. Smart pump medication library logs and their reporting software record medication and dose selections made by users, as well as cancellations of selections and the time between these actions. Analysis of these data adds quantitative data to the detection of these kinds of errors. Objective We aimed to establish, in a reproducible and reliable study, baseline data to show how metrics in the set-up and programming phase of intravenous medication administration can be produced from medication library near-miss error reports from infusion pumps. Methods We performed a 12-month retrospective review of medication library reports from infusion pumps from across a facility to obtain metrics on the set-up phase of intravenous medication administration. Cancelled infusions and resolutions of all infusion alerts by users were analyzed. Decision times of clinicians were calculated from the time-date stamps of the pumps’ logs. Results Incorrect medication selections represented 3.45% (10,017/290,807) of all medication library alerts and 22.40% (10,017/44,721) of all cancelled infusions. Of these cancelled medications, all high-risk medications, oncology medications, and all intravenous medications delivered to pediatric patients and neonates required a two-nurse check according to the local policy. Wrong dose selection was responsible for 2.93% (8533/290,807) of all alarms and 19.08% (8533/44,721) of infusion cancellations. Average error recognition to cancellation and correction times were 27.00 s (SD 22.25) for medication error correction and 26.52 s (SD 24.71) for dose correction. The mean character count of medications corrected from initial lookalike-soundalike selection errors was 13.04, with a heavier distribution toward higher character counts. The position of the word/phrase error was spread among name beginning (6991/10,017, 69.79%), middle (2144/10,017, 21.40%), and end (882/10,017, 8.80%). Conclusions The study identified a high number of lookalike-soundalike near miss errors, with cancellation of one medication being rapidly followed by the programming of a second. This phenomenon was largely centered on initial misreadings of the beginning of the medication name, with some incidences of misreading in the middle and end portions of medication nomenclature. The value of an infusion pump showing the entire medication name complete with TALLman lettering on the interface matching that of medication labeling is supported by these findings. The study provides a quantitative appraisal of an area that has been resistant to study and measurement, which is the number of intravenous medication administration errors of wrong medication and wrong dose that occur in clinical settings.

Changes in medication administration error rates associated with the introduction of electronic medication systems in hospitals: a multisite controlled before and after study

BackgroundElectronic medication systems (EMS) have been highly effective in reducing prescribing errors, but little research has investigated their effects on medication administration errors (MAEs).ObjectiveTo assess changes in MAE rates and types associated with EMS implementation.MethodsThis was a controlled before and after study (three intervention and three control wards) at two adult teaching hospitals. Intervention wards used an EMS with no bar-coding. Independent, trained observers shadowed nurses and recorded medications administered and compliance with 10 safety procedures. Observational data were compared against medication charts to identify errors (eg, wrong dose). Potential error severity was classified on a 5-point scale, with those scoring ≥3 identified as serious. Changes in MAE rates preintervention and postintervention by study group, accounting for differences at baseline, were calculated.Results7451 administrations were observed (4176 pre-EMS and 3275 post-EMS). At baseline, 30.2% of administrations contained ≥1 MAE, with wrong intravenous rate, timing, volume and dose the most frequent. Post-EMS, MAEs decreased on intervention wards relative to control wards by 4.2 errors per 100 administrations (95% CI 0.2 to 8.3; p=0.04). Wrong timing errors alone decreased by 3.4 per 100 administrations (95% CI 0.01 to 6.7; p<0.05). EMS use was associated with an absolute decline in potentially serious MAEs by 2.4% (95% CI 0.8 to 3.9; p=0.003), a 56% reduction in the proportion of potentially serious MAEs. At baseline, 74.1% of administrations were non-compliant with ≥1 of 10 procedures and this rate did not significantly improve post-EMS.ConclusionsImplementation of EMS was associated with a modest, but significant, reduction in overall MAE rate, but halved the proportion of MAEs rated as potentially serious.