Continuing coverage of Patient Safety Awareness Week
According to the Food and Drug Administration, medication errors cause at least one death every day and injure approximately 1.3 million people each year in the United States. And countless so-called "near-misses" go unreported. The problem isn't specific to hospitals; it's also an issue in nursing homes, retail pharmacies, outpatient clinics, school nurse's offices, and in front of medicine cabinets in homes across the country. Errors can also happen when a doctor, physician's assistant or nurse practitioner writes a prescription, or even further back in the drug pipeline, if medicines are mispackaged or mislabeled at the factory where they're made.
Medication safety is an important priority at Penn Medicine, and steps are taken throughout the hospital, from the pharmacy to the bedside, to make sure patients receive the proper drugs.
Here's quick mnemonic device used here to help staff think through the factors that contribute to medication errors each time they give a drug -- the "5 Rights" of Safe Medication Administration:
Right Drug: There's little oversight of drug labeling, so the colored caps on vials can trick the eye, and some drug names sound alike when spoken out loud or too quickly (heparin vs. epinephrine is one example where a misheard name could be deadly). Careful reading of labels helps, for sure, but technology increasingly plays a role. HUP's electronic medical records system and medication dispensing system work together to make sure that staff take from the dispensing cabinet only medicine that has been ordered for the patient in question. Our pharmacy also marks high-risk medications -- like paralyzing drugs -- with brightly colored stickers and warning text to draw extra attention to them before they're administered.
Right Dose: In addition to the possibility of giving too much or too little of a medication, drugs are made in different concentrations/strengths, so even if the pill looks the same, or the volume in the syringe or IV bag seems correct, there's more to watch out for. One of HUP's patient safety goals calls for the use of standardized drug concentrations to eliminate errors in this area. We've also eliminated certain abbreviations from charts and modified the way that dosages are written. Dangling zeros, for instance, aren't used, lest the eye sweep over a decimal point and mistake 1.0 for 10 milligrams. Conversely, drug dosages of less than one unit get a zero in front of the decimal point -- it's 0.5, not .5 -- to avoid the possibility of overdosing a patient.
Right Route: Is the drug given by mouth, IV, syringe, inhaler, etc? For patients who can't eat or drink before or after surgery or because of their illness, for instance, this is an important distinction.
Right Time: How often does the patient need this medication? Have they missed any doses?
Right Patient: Check ID bands and ask patient to verify, too.
We're also working to make sure patients take their medicines properly once they go home. Issues around so-called "medication reconciliation" are a common issue when patients are leaving the hospital. They may have been taken off a regular medication during their hospitalization, or had a bevy of new ones added to their regimen, and it can be hard to make sense of what to take after they go home. One of our Unit-Based Clinical Leadership Initiatives -- which are multidisciplinary teams within individual hospital units that work together to improve care and solve common problems -- deals with medication teaching, making sure that when patients are discharged, they understand what new medications they're taking, what they're for, what do do if they miss a dose, possible side effects, and important safety measures such as whether to eat with food or drug and what foods should and should not be combined with it (grapefruit juice, for instance, interferes with how drugs for everything from high cholesterol to allergies to depression are broken down in the body).
Of course, patients can also be proactive about ensuring their own safety. One easy way you can help is by always carrying a list of any medications you take – including herbal supplements – as well as any drug or food allergies they have. That little piece of paper could make a big difference in an emergency.