Reducing Medication Errors

PHAR 841 – PHAR MACY PR AC T I CE MAN AGEMEN T

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Objectives
Describe the law that requires pharmacies to
have a quality assurance program
Define the steps to investigate errors
Classify the requirements of a quality
assurance program
Explain how to report errors to ISMP
Differentiate MERP elements in a hospital
versus community setting
Interpret system errors that may occur

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 What is the Role of the Community Pharmacist?

Business and Professions Code 4125: Pharmacy Quality Assurance Program Required; Records Considered Peer
Review Documents* (a) Every pharmacy shall establish a quality assurance program that shall, at a minimum,
document medication errors attributable, in whole or in part, to the pharmacy or its personnel. The purpose of
the quality assurance program shall be to assess errors that occur in the pharmacy in dispensing or furnishing
prescription medications so that the pharmacy may take appropriate action to prevent a recurrence.

* Peer Review Documents are not discoverable in a court of law

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 1711. Quality Assurance Programs
(c) (1) Each quality assurance program shall be managed in accordance with written policies and procedures
maintained in the pharmacy in an immediately retrievable form
(2) When a pharmacist determines that a medication error has occurred, a pharmacist shall as soon as
possible:
(A) Communicate to the patient or the patient’s agent the fact that a medication error has occurred and the steps
required to avoid injury or mitigate the error.
(B) Communicate to the prescriber the fact that a medication error has occurred.

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How Do You Address This?
Keep accurate records:
◦ Date, location, and participants in the quality assurance review;
◦ Pertinent data and other information related to the medication error(s) reviewed;
◦ Findings and determinations; and
◦ Recommended changes to pharmacy policy, procedure, systems or processes, if any.

Have Policies and Procedures regarding the Quality Assurance process

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Investigate Errors
Once a medication error has been discovered, the pharmacy has two business days to investigate
the error (suggest doing a root cause analysis).
All medication errors will be compiled and reviewed in a Quality Assurance Review
◦ Policy should address how often the review occurs and by whom
◦ Policy should allow for emergency review in case of a major error (e.g. life-threatening)

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How to Decrease Medication Errors from Dr. Gunther
Develop a “plan” to substantially reduce medication-related errors
◦ Policies and Procedures
◦ Medication Error Reporting System

Conduct an annual review to assess effectiveness of plan

Dr. Gunther’s PHAR 741 Presentation “Introduction to Medication Errors and Adverse Drug Events”

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 Roles of a Pharmacist
Assessment:
◦ Examine/evaluate causes
◦ Analyze data to determine trends, significance and frequency

Prevention strategies:
◦ Develop interventions towards med error reduction
◦ Establish goals and measurable standards
◦ Monitor interventions and make changes

Reporting
◦ Communicate results to all health care providers, patients and caregivers
◦ Promote reporting of med errors to national system for review and analysis

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May Use ISMP
https://www.ismp.org/errorReporting/Default.aspx
While ISMP widely disseminates case studies of events and what has been learned about the
causes and prevention of medication and vaccine errors, identifiable details regarding
individual events, where they occurred, and the identity of patients, involved staff, and
reporters remains strictly confidential. Your identity, affiliation, and location will NOT be
revealed in any ISMP publications.

Institute for Safe Medication Practices (ISMP)

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Simple ISMP Error Reporting Form

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 What to Report to ISMP
ISMP encourages healthcare practitioners and consumers to report medication errors, vaccine
errors, preventable adverse drug reactions, close calls, and hazards to ISMP. Examples include, but
are not limited to:
◦ Errors when prescribing, transcribing, dispensing, and administering medications/vaccines
◦ Errors related to patient monitoring of the effects of medications and vaccines
◦ Errors with medications or vaccines that are captured before they reach the patient
◦ Potential or actual confusion regarding look- and sound-alike drug or vaccine names, packaging similarities,
or label ambiguity
◦ Misuse, nonuse, or malfunction of medication-related tools (e.g., syringes, needles), equipment (e.g.,
tubing, infusion pumps), and technology (e.g., computerized order entry systems, barcode scanning)

Please do NOT submit any provider- or patient-identifiable information.

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Which of the 11 MERP Elements are Involved in
Community Pharmacy?
1. Prescribing 6. Dispensing
2. Prescription order 7. Distribution
communication 8. Administration
3. Product labeling 9. Education
4. Packaging and 10. Monitoring
nomenclature
11. Use
5. Compounding

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System Based Med Errors
ISMP has identified 10 key elements that have the greatest influence on
medication use system. System based causes of medication errors can be
directly traced to weaknesses or failures in these key elements:
1. Patient information 6. Drug storage, stock, and
distribution
2. Drug information
3. Communication of drug 7. Environmental factors
information 8. Staff competency and education
4. Drug packaging, labeling, 9. Patient education
and nomenclature
5. Drug device acquisition 10. Quality processes; and risk
and use management

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Summary
Implement a Quality Assurance Program
Write Policies and Procedures describing your QA Program
Investigate Medication-Related Errors
Develop an Action Plan to try to prevent the error from happening again
Maintain records of Medication Error Reviews
Utilize the resources of ISMP

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