What’s causing medication errors, and what can your facility do to mitigate the risk of making them?
The wrong drug. The wrong formulation. The wrong label. The wrong frequency. The wrong duration. These are many ways that medication errors can happen.
And they do happen, frequently. According to the U.S. Food and Drug Administration, the organization receives more than 100,000 reports each year associated with a suspected medication error.
Of course, it’s not simply a matter of carelessness or ineptitude. Experts attribute medication errors to a number of factors, some of which are well beyond the average healthcare professional’s control. These same experts suggest that providers everywhere refresh themselves on established medication safety practices and protocols.
The modern healthcare system has gotten increasingly complex over time.
And patients are no longer firmly at the center of this system, which is one of various factors contributing to an environment where mistakes are more likely to occur, says Teri Dreher, RN, CCM, BCPA, owner and founder of NShore Patient Advocates in Chicago.
“For example, hospitals are trapped between tight financial constraints and attending to patients,” she says, adding that facilities are also often under pressure to quickly discharge patients, sometimes too quickly, in order to free up beds.
“Many hospitals are chronically understaffed with regard to nurses—the patient’s primary point of contact—and support staff such as janitors, who are charged with the very important job of keeping the hospital clean.”
Physicians frequently find themselves in similar circumstances—spending hours documenting health records and completing insurance forms. This time was once spent on patients, says Dreher.
“At the same time, they’re reimbursed by health insurers at ever-shrinking rates, even as their malpractice insurance premiums soar,” she continues.
“This is why many doctors are increasing their patient load or relying on less qualified physician assistants to handle their caseload. [The] end result is less one-on-one time with patients and a greater risk of something falling through the cracks.”
Deborah Sadowski, RPh, MHA, director of pharmacy services at Deborah Heart and Lung Center in Browns Mills, N.J., points to three primary drivers of medication errors in the current healthcare environment.
Transition of care, for example, can include movement within one facility—from admission, from one unit to another, or at discharge—or between facilities.
These moves open patients up to risk for errors, says Sadowski.
Discharge from a hospital, for instance, is a very intricate process.
“[This is] a high vulnerability point in a patient’s care related to clear communication and understanding of relevant information at the time of hand-off to the new caregivers, be it at another healthcare facility or the patients themselves,” says Sadowski.
“It is essential that there be clear and effective provider communication at every step in this process to assure medications are continued, stopped, or changed appropriately for the new level of care to which the patient is moving.”
Staffing and drug shortages add to the strain
Indeed, continuity is critical in maintaining medication safety. As is standardization, says Sadowski, pointing out that the growing number of drug shortages adds to the potential for more medication errors and poorer patient outcomes.
“This occurs because the healthcare team may be forced to use medications in different concentrations or dosage forms than the standards they are used to, or even use alternative, less familiar drugs that might be second-line choices for the desired therapy,” she continues. “These can lead to near misses, errors or even adverse outcomes, despite everyone’s best efforts.”
Indeed, best efforts are not always enough. Especially when staffing concerns place greater demands on healthcare professionals everywhere.
Consider statistics from the U.S. Department of Health and Human Services, which projects significant imbalances in supply and demand for nurses across U.S. states. In 2030, for example, there figures to be a surplus of more than 50,000 full-time RN equivalents in Florida, while California faces a shortage of more than 44,000, according to the HHS.
The strain that staffing issues put on pharmacists and all healthcare workers “can have a detrimental effect on patient safety if pushed too far,” says Sadowski.
When faced with decreasing reimbursements, staff reductions are one area that facilities target as a way to cut costs, she says.
“Let’s hope that the the healthcare team and staff are up to providing safe and effective care during this stressful pandemic period; perhaps some rethinking on reimbursements will occur in the future to assure adequate staffing and equipment is available when needed.”
As Sadowski points out, the U.S. Food and Drug Administration has taken steps to help minimize the number of drug shortages.
For example, Title X of the Food and Drug Administration Safety and Innovation Act (FDASIA) provided the FDA new authorities designed to help the agency combat drug shortages, such as broadening the scope of the early notification provision by requiring all manufacturers of certain medically important prescription drugs to notify the FDA of a permanent discontinuance or a temporary interruption of manufacturing.
FDASIA also required the FDA to issue a non-compliance letter to manufacturers that fail to comply with the drug shortage notification requirements and, if the company does not have a reasonable basis for failing to comply, to make the letter and the company’s response available to the public.
Of course, pharmacies, healthcare facilities, and healthcare professionals must keep an eye on drug shortage reports from organizations such as the FDA or the American Society of Health-System Pharmacists (ASHP), in order to manage drug supply based on the most recent information, says Sadowski.
To help cut down on shortage-related prescription errors, she recommends strategies such as therapeutic substitutions, changing IV medications to oral dosage forms when possible, or in some cases, considering transitions to non-pharmacologic interventions when shortages occur.
Beyond addressing ongoing drug shortages, there are additional steps that facilities and providers must take to reduce the likelihood of medication errors, of course (see sidebar for a checklist, courtesy of The Agency for Healthcare Research and Quality.)
This starts at the prescription phase, with medication reconciliation at transition of care, and computerizing order entry, for example, to eliminate the risk of human error.
Clinical pharmacists should also oversee the dispensing of medications, when “tall-man” lettering should be used to minimize confusion between medications that look or sound alike, for instance.
And, when administering medication, providers should always adhere to the “Five Rights” of medication safety, and barcode medication administration to make sure the right drug is going to the right patient, for example.
Ultimately, the implementation of—and strict adherence to—these protocols is a carefully coordinated, multi-step process that requires communication throughout the healthcare system, says Sadowski.
“Collaboration among healthcare providers, particularly physicians and pharmacists, is essential to assure accurate information is shared and all can work together for the best care of our patients.”
- U.S. Food and Drug Administration, 2019. Accessed April 20, 2020
2. Health Resources and Service Administration, 2017. Accessed April 21, 2020
3. U.S. Food and Drug Administration, 2018. Accessed April 23, 2020
4. Institute for Healthcare Improvement, 2015. Accessed April 24, 2020
Consult Your Medication Safety Checklist
Each step of the patient care process presents risks for medication errors. The Agency for Healthcare Research and Quality provides safety strategies to adopt at each stage of the patient pathway.
- Avoid unnecessary medications by adhering to conservative prescribing principles
- Computerized provider order entry
- Medication reconciliation at times of transitions in care
- Computerized provider order entry to eliminate handwriting errors
- Clinical pharmacists to oversee medication dispensing process
- Use of “tall man” lettering and other strategies to minimize confusion between look-alike, sound-alike medications
- Automated dispensing cabinets for high-risk medications
- Adherence to the “Five Rights” of medication safety
- Barcode medication administration to ensure medications are given to the right patient
- Minimize interruptions to allow nurses to administer medications safely
- Smart infusion pumps for intravenous infusions
- Multicompartment medication devices for patients taking multiple medications in ambulatory or long-term care settings
- Patient education and revised medication labels to improve patient comprehension of administration instructions
- The Agency for Healthcare Research and Quality, 2019. Accessed April 25, 2020