The Weekly Roundup: Medication Errors (5.25.18)
In 2017, a Missouri nurse called in a prescription to a pharmacy technician following the discharge of a patient from the hospital. The tech erred in transcribing the prescription, the pharmacist didn’t catch the error, and the pharmacy system didn’t flag it. A month later, the patient was dead and the pharmacy plead guilty to negligence.
According to the FDA, medication errors harm 1.3 million individuals each year and kill at least one person a day. Healthcare costs from medication errors in the U.S. are estimated to be $21 billion per year. The repercussions of a mistake are enormous, which makes transparency about human error a challenge.
In a recent article by Drug Topics on medication errors, one pharmacist said, “Until we create a culture that encourages improvement of the system that fosters the errors that are committed, we cannot expect candor and transparency in error reporting.” The magazine was trying to dig into how learning from their mistakes happens in an environment where the stakes are so high. The errors described were introduced in a range of ways—keystroke error in writing out dosage, miscalculations, refilling discontinued drug therapies, and miscommunications among them.
One respondent pointed out that it is important NOT to be bullied when any important "flag" occurs while verifying orders. Explain you are calling the physician because you always do to avoid putting prescribers on the defensive. Clarification is often in order—and phone calls are best. Prescription verification questions tracked between a group of independent pharmacies in Connecticut found that person-to-person verifications resulted in an 80 percent resolution rate on prescription questions, compared to 40 percent by faxing.
Another pharmacist respondent recommends always practicing the STAR safety technique (Stop, Think, Act, Review) to self-check, as well as gaining an independent second (or confirmatory) calculation of all extemporaneous compounds prior to mixing and/or checking product. Teach technicians to verify the prescription with the patient when they retrieve a voicemail request to see exactly what they need refilled. For newer practitioners especially, here are some great tips for going through the verification process.
There are plenty of reasons that errors occur—not the least of which is human error. As collaboration expands among pharmacists and physicians, it’s safe to assume pharmacists will have ample opportunity to demonstrate the profession’s contributions to keeping people safe.
MEMORIAL DAY OBSERVED
“Our debt to the heroic men and valiant women in the service of our country can never be repaid. They have earned our undying gratitude. America will never forget their sacrifices.” – Harry S. Truman
This weekend, we honor those who have made the ultimate sacrifice for our country. We hope that you, your family, and your communities have a safe holiday.
Here are a few other stories that might be of interest:
- It’s not just about chemistry. Here are four ways pharmacists can improve patient communication.
- Stay on top of the latest in HIV treatment with these clinical guidelines for the new therapy, Juluca.
- Pain sufferers just can’t catch a break. It’s not just opioids that are dangerous. Here are some tips for promoting appropriate NSAID use among your patients.
- The FDA has approved a new 14-day treatment intended to lessen symptoms associated with abrupt opioid withdrawal.
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