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Pharmacists Play Key Role in Reducing Medication Errors Among Hospitalized Patients

Drugs used in hospitals are meant to save lives – to battle infections, kill cancer cells, control pain, steady uneven heart beats, and prevent blood clots from forming when patients are unable to get out of bed and move around. But despite these healing powers, medication errors are common, and the consequences can be severe. 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" with incorrect dosing or drug mix-ups go unreported. In response, the federal government and hospitals across the nation have made cutting medication errors a cornerstone of patient safety initiatives.

Baligh Yehia, MD, MSHP, MPP, an Infectious Diseases fellow at the University of Pennsylvania’s Perelman School of Medicine, recently published a study in the journal Clinical Infectious Diseases examining the prevalence of antiretroviral medication errors among hospital patients infected with HIV. Medication errors are a risk during hospitalizations of all kinds, but HIV patients are especially vulnerable.

“HIV-infected individuals are at increased risk of medication errors because they have complex medication regimens, often deal with other medical conditions, and may encounter inpatient providers who lack experience with antiretroviral therapy,” Yehia said.

Errors with those medications can have serious long-term consequences if they’re not identified – potentially leading to drug resistance, treatment failure, or even death. Yehia and his co-authors from Penn and the Johns Hopkins University School of Medicine found ART medication errors – including incorrect or incomplete dosing, incorrect timing of administration, or administration of drugs that may have caused adverse reactions with one another -- in nearly 30 percent of cases studied. They noted, however, that the errors were quickly identified and corrected on the second day of hospitalization, at the time when pharmacists reviewed medication orders from the day before.

Although the authors did not specifically examine effects of pharmacist review on errors, they say the timing of the fixes indicates that their role is an important checkpoint to ensure that the drugs patients receive in their rooms are, in fact, correct and safe. The paper’s senior author, Kelly Gebo, MD, MPH, an associate professor of Medicine and Epidemiology at the Johns Hopkins University School of Medicine, says providing pharmacy review of medication regimens even earlier in a patient’s hospital stay may greatly reduce medication error rates across the board. For hospitals without robust pharmacy resources or staffs, she suggests targeted programs could focus on patients at the greatest risk of drug errors, such as those infected with HIV.

Despite the growing use of electronic medical records, they don’t typically follow patients as they seek care at different hospitals or physician practices, so clinicians often must rely on a patient’s own recounting of their medication history and regimen, or enlist help from a family member who may not be involved in their day-to-day care. That process leaves plenty of room for error – one that can often be mitigated by pulling pharmacists into the process, says Yehia’s co-author, Jimish Mehta, Pharm.D, a post-doctoral research fellow in Penn Medicine’s Center for Epidemiology and Biostatistics and a Clinical Pharmacy Specialist for Infectious Diseases in the department of Pharmacy. “Pharmacists are unique members of the multidisciplinary team that can improve the process because of their familiarity with medication dosage forms, brand and generic names, and outpatient pharmacy practices,” he says.

At the Hospital of the University of Pennsylvania, pharmacists are integrated into the multidisciplinary care team on each patient unit, especially during key points where errors are most likely to happen – shortly after the patient is admitted to the hospital, and during their discharge process when they’re preparing to handle new medications on their own at home. Within 24 hours of a patient’s admission, pharmacists meet with them to interview them about their medication history – a step that helps verify the accuracy of the information obtained by nurses and physicians. They also take extra steps to ensure they have the patient’s full medication history, by contacting outpatient pharmacies and family members, if necessary, says Danielle Ciuffetelli, Pharm.D., the Infectious Diseases pharmacy resident.

These efforts add an extra layer of protection to a process that in recent years has been increasingly reliant on information technology such as computerized drug ordering systems. These tools aim to eliminate math errors when calculating dosages, slip-ups related to indecipherable handwriting, or miscommunications between different providers. These programs have been touted as ways to improve patient safety, but Yehia and his colleagues note in their new study that, in fact, they may actually increase the odds of making certain types of mistakes. A Penn Medicine study published in the Journal of the American Medical Association in 2005, for instance, found that these types of tools tended to display information a way that fragmented patients’ complete medication lists, and presented data in ways that were confusing to users, such as creating the impression that pharmacy inventory information was actually dosing guidelines.

Close attention from pharmacists, however, helps ensure that those mistakes don’t make it to the bedside.

“Our work is continual throughout each patient’s hospital stay, with pharmacists verifying new orders for accuracy when drugs are first prescribed, and ending with patient counseling when they’re discharged, when we emphasize each drug’s indication, dose, and adverse effects,” Ciuffetelli says. “Pharmacists are helping during the crucial transition-of-care phases, to ensure that fewer medication errors are being made.”

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