Preventing Medication Errors (2007) / Chapter Skim
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The Centers for Medicare and Medicaid Services sponsored this study by the Institute of Medicine (IOM) with the aim of developing a national agenda for reducing medication errors based on estimates of the incidence of such errors and evidence on the efficacy of various prevention strategies.
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This report provides guidance on how to implement error prevention strategies in hospitals, long term care, and ambulatory care. Establishing and maintaining a strong providerpatient part nership is a key approach for reducing medication errors.
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. THE LEVEL AND CONSEQUENCES OF MEDICATION ERRORS ARE UNACCEPTABLE Rates of Errors and Preventable Harmful Events Are High The frequency of medication errors and preventable adverse drug events (ADEs)
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Further, since prescribing and administration errors account for about threefourths of medication errors (Leape et al., 1995) , the committee conservatively estimates that on average, a hospital patient is subject to at least one medication error per day.
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Most of what is known relates to additional health care costs associated with preventable ADEs, which represent the injuries caused by errors. For hospital care, there is one estimate of the extra costs of inpatient care for a preventable ADE incurred while in the hospital -- $5,857 (Bates et al., 1997)
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Effective Error Prevention Strategies Are Available According to most studies, at least a quarter of all harmful ADEs are preventable. Moreover, many efficacious error prevention strategies are available, especially for hospital care.
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Millions of Americans take prescription drugs each year without being fully informed by their providers about associated risks, contraindications, and side effects. When clinically significant medication errors do occur, they usually are not disclosed to patients or their surrogates unless injury or death results.
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. First, they can verify the patient's current medication list for appropriateness at each encounter, and they can ensure that this list is accurate at times of transition between care settings.
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· Be aware of where to find educational material in your local community and at reliable Internet sites. Ambulatory Care/Outpatient Clinic · Have the prescriber provide in writing the name of the drug (brand and generic names, if available)
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Many of these barriers can be overcome by improved consumer-oriented drug information, efforts on the part of providers to respond to the challenges faced by their patients, and actions by health care organizations to adopt a culture of safety and make more extensive use of information technology.
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· Consultation on their medications should be available to pa tients at key points in the medication-use process (during clinical decision making in ambulatory and inpatient care, at hospital dis charge, and at the pharmacy)
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Such efforts require stan dardization of pharmacy medication information leaflets, improve ment of online medication resources, establishment of a national drug information telephone helpline, the development of personal health records, and the formulation of a national plan for the dissemination of medication safety information. · Pharmacy medication information leaflets should be standard ized to a format designed for readability, comprehensibility, and usefulness to consumers.
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ELECTRONIC PRESCRIBING AND MONITORING FOR ERRORS IN ALL CARE SETTINGS ARE ESSENTIAL Safe medication use requires that clinicians synthesize several types of information, including knowledge of the medication itself, as well as understanding of how it may interact with coexisting illnesses and medications and how its use might be monitored. Several electronic supports can help providers absorb and apply the necessary information.
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, the use of technology will undoubtedly lead to major improvements in all settings. In acute care, technologies should target prescribing by including computerized provider order entry with clinical decision support.
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. They should implement active internal monitoring programs so that progress toward improved medication safety can be accurately demonstrated.
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Recommendation 3: All health care organizations should immedi ately make complete patient-information and decision-support tools available to clinicians and patients. Health care systems should capture information on medication safety and use this information to improve the safety of their care delivery systems.
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Thus the numbers and types of patients for whom clinical outcomes are measured must be greatly increased to elucidate the proper dosing of drugs in individuals and within subgroups. Of critical concern is the need for transparency through the publication of clinical studies in a national repository to advance medication safety, error prevention, and public knowledge.
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The committee believes the expanded implementation of unit-of-use packaging in this country warrants further investigation. Another issue related to medication safety is the common practice of providers offering free samples of prescription drugs to patients to start them on their medications quickly, to adjust prescribed doses before the full prescription is filled, and to offset medication costs for indigent and underinsured patients.
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· AHRQ should fund studies to evaluate the impact of free samples on overall patient safety, provider prescribing practices, and consumer behavior (e.g., adherence to the medication regi men) , as well as alternative methods of distribution that can im prove safety, quality, and effectiveness.
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· AHRQ should support additional research to determine speci fications for alert mechanisms and intelligent prompting, as well as optimum designs for user interfaces. Research on Medication Errors: Incidence Rates, Costs, and Prevention Strategies In reviewing the research literature, the committee concluded that large gaps exist in our understanding of medication error incidence rates, costs,
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The primary focus of research on medication errors in the next decade should be prevention strategies, recognizing that to plan an error prevention study, it is essential to be able to measure the baseline rate of errors. Evidence on the efficacy of prevention strategies for improving medication safety is badly needed in a number of settings, including care transitions, ambulatory care (particularly home care, self-care, and medication use in schools)
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This agenda requires that all stakeholders -- patients, care providers, payers, industry, and government, working together -- commit to preventing medication errors. Given that a large proportion of injurious drug events are preventable, this proposed agenda should deliver early and measurable benefits.
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1995a. Relationship between medication errors and adverse drug events.
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2001. Medication errors and adverse drug events in pediatric inpatients.
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