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October 31 to November 4, 2011 is the Seventh Annual Canadian Patient Safety Week with the theme "ask listen talk" aimed at raising awareness of patient safety issues and solutions. Obviously pharmacists have a key role and responsibility in ensuring safe medication use with every patient encounter every day: from recommending non-prescription products to dispensing a prescription to performing medication reviews.
Medication errors can be defined as "... any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer."1 Some medication errors are corrected before they reach the patient, or reach the patient but cause no harm. Some errors result in harm varying from minor transient side effects, to those requiring additional interventions, increased monitoring, hospitalization, or even death.1,2
The data on rates and impact of medication errors and preventable adverse drug events, especially in the Canadian ambulatory setting, is sparse, but available reports indicate that medication safety problems remain a serious concern:
The literature also indicates that certain populations (e.g. elderly or pediatric, liver or kidney disease, mentally ill) are at higher risk for medication errors and adverse drug events.7-9
Medication use can be discussed as a series of processes and subprocesses beginning with the prescription, followed in order by transcription and verification, dispensing, administration and consumption, monitoring and evaluation.5 The medication use system depends on patient data, drug information, staff and patient education, and well-designed systems and environments to minimize the chance of error.10 The goal is getting the right drug, in the right dose, to the right patient by the right route, at the right time, for the right reason, with the right documentation (Figure 1). The many ways medication safety can be improved in individual practice and patient situations is beyond the scope of this article. However, identifying deficiencies in the key elements above or in the medication use processes, and whether the "right" goals have been met (and if not, why not) can help identify problem areas.
When things go wrong - report it!
As with adverse drug reactions, reporting and analyzing medication errors (including near misses) is key to prevention. Under-reporting hinders preventative measures. "Only by sharing the information can we ensure that everyone learns how to prevent the same error."11 Health professionals and patients can report medication errors freely and anonymously via the Institute for Safe Medication Practices Canada website.
Figure 1: Key elements, processes, and goals of the medication use system
Key elements: |
support |
Medication use processes: |
to achieve |
Goals: |
Patient information (e.g. age, weight, allergies, lab results, comorbidities, preferences) |
Optimal prescribing Order transcription and verification Product selection and dispensing Medication administration and consumption Monitoring and evaluation of therapy |
Right drug Is this the right drug for this patient? Is it the right product and strength? Right dose Is this the right dose for this patient? Right patient Has the patient identity been verified? Right route Right time Are labeled directions clear and understood by the patient or caregiver? Right reason Is there an indication for the drug? Is there a condition in need of treatment? Right documentation Are problems, treatment plans, and changes documented and communicated to those who need to know? |
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Current, accurate, and accessible drug information and clear communication of the same |
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Safe drug nomenclature, labeling and packaging (e.g. be aware of look-alike, sound-alike drugs) Standardization (e.g. administration times, drug strengths or concentrations) Safe technologies and practices (e.g. drug delivery devices, independent double checks) |
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Reduction of environmental factors that can lead to errors (e.g. poor lighting, distractions, poor workflow, high workloads) |
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Staff competency and education |
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Patient education and encouragement (e.g. ensure patients know and understand what they are taking and why; encourage them to ask questions, seek answers, and report concerns) |
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Quality processes and risk management strategies (e.g. redesign systems and processes that lead to errors; improve detection and correction of errors before they reach the patient) |
Helpful online resources:
Canadian Patient Safety Institute: www.patientsafetyinstitute.ca
Institute for safe Medication Practices Canada: www.ismp-canada.org
Safer Healthcare Now!: www.saferhealthcarenow.ca
Written by Raymond Li, BSc(Pharm), MSc. Reviewed by Laird Birmingham, MD, FRCPC, MHSc
References:
©2012 B.C. Drug and Poison Information Centre
A version of this document was published in BCPhA's The Tablet. 2011; 20(5): 22-23.