According to the Centers for Medicare and Medicaid Services, the number one cause of re-admittance to the hospital is non-compliance to medication. The FDA reports that since 1992 they have received notification of a startling 30,000 medication errors and more than 7,000 deaths a year as a result. This count does not include the number of medication errors that go unreported. “One study showed that more than half of patients at hospitals nationwide had an error in their medications, such as the wrong drug, the wrong dosage, the wrong frequency, or a potentially dangerous interaction with another drug” (bsahs.org). One report from the FDA included a situation where a physician ordered a 260mg prep of Taxol, but the patient received 260 mg of Taxotere from the pharmacist instead. This mistake cost the patient their life a few days later. It’s easy to make this type of mistake when we get into a routine. The steps and precautions pharmacists take can become mundane and “second nature”, which can become ineffective and dangerous for patients. When we mindlessly go through the motions, accidents are more likely to occur.
The FDA is working on different strategies to reduce the occurrence of medication errors. Drug name confusion, as in the example above, is a big cause of medication errors. “To minimize confusion between drug names that look or sound alike, the FDA reviews about 300 drug names a year before they are marketed. ‘About one-third of the names that drug companies propose are rejected,’ says Phillips. The agency tests drug names with the help of about 120 FDA health professionals who volunteer to simulate real-life drug order situations. ‘FDA also created a computerized program that assists in detecting similar names and that will help take a more scientific approach to comparing names,’ Phillips says” (FDA.gov). The rejection of certain drug names that sound like a medication already on the market is one action the FDA has taken in the fight against medication errors.
What can you and your pharmacists do to decrease medication errors in your area? How about changing your precautionary steps every quarter to reduce errors due to mundane repetition? What other ideas do you have?
A Hospital Minimizing Risk & Creating Jobs for Pharmacists
I think we can all agree that it will take change and testing different strategies to come up with long term solutions to reducing medication errors. A great idea we came across in an industry blog to reduce medication errors is a new two-part process that the Pharmacy Department at BSA Health System in Amarillo, Texas has implemented. Four pharmacists will now be staffed for patient education upon discharge to ensure patients fully understand how to take their medications before discharge preventing unnecessary readmissions, and four additional pharmacists assigned solely to the ER Department to perform medication use evaluation for each patient. Their goal is by educating and making sure each patient is well informed on the importance of each medication, they hope to see a significant improvement of proper medication usage within their patients including a reduction in medication errors.