When a 71-year-old woman left the hospital after being treated for uncontrolled hypertension and acute kidney injury, her medication list included prescriptions for amlodipine (Norvasc), metoprolol, and doxazosin.
Over the next few months, the woman’s health continued to decline and she experienced fatigue, personality changes, and a “stoic” facial expression. She returned to the hospital several times and underwent an angioplasty after complaining of chest pain.
On her third trip to the emergency room, she was described as having a shuffling gait and bradykinesia. Her creatinine levels were elevated, but medical professionals could not determine the cause of her symptoms until a medication reconciliation revealed she’d been mistakenly given the antipsychotic Navane rather than Norvasc at her outpatient pharmacy three months earlier.
It was a mistake that caused significant negative health effects and was chronicled in a 2016 Journal of Community Hospital Internal Medicine Perspectives article.
Experts say this isn’t an isolated incident.
Medical errors of all kinds, including medication errors, are now the third highest cause of death in the United States and may be responsible for 10% of all deaths in the country, according to a 2016 study by Johns Hopkins Medicine. According to the National Academy of Medicine, preventable medication errors harm 1.5 million Americans annually and cost hospitals an additional $3.5 billion each year.
“I think the problem is becoming worse because this is a complex medical system that we have,” says Deborah A. Pasko, PharmD, MHA, senior director of medication safety and quality for ASHP.
Strategies to prevent medication errors in recent years include a move to electronic prescribing and adding barcodes to drug products. But experts say these efforts have not eliminated the need for vigilance among pharmacists, technicians, and other healthcare professionals in the community and hospital setting. Here’s more on the actions pharmacists need to take to avoid some of the most common medication errors.
In busy community pharmacy settings, the most common errors are related to processing more than one prescription in a confined space, Drug Topics Editorial Advisor Michael R. Cohen, RPh, MS, FASHP, president of the Institute for Safe Medication Practices (ISMP), says. ISMP is devoted to improving medication safety and runs a voluntary practitioner medication-error reporting program.
“They put one patient’s prescription in another patient’s prescription, and then once it’s in the bag, they often will seal the bag,” Cohen says. The patient is sent home with the wrong medication and may not realize it. “It’s a very common thing when people come home with someone else’s bag due to this type of mix-up,” he says. “Usually it’s because [pharmacists] are working quickly.”
Cohen says the error can be avoided by leaving the prescription out of a bag until the patient arrives to pick up the medication.
The Medicine Shoppe in Two Rivers, WI, goes one step further. It performs a “show and tell” on every prescription. Drug Topics Editorial Advisor Marvin Moore, PharmD, owner of the pharmacy, says during patient counseling sessions they actually open up the bottle, pour some of the pills out onto the counter, and show them to the patient. This not only ensures the patient has the right prescription before they leave the pharmacy, but also opens up a dialogue between the patient and pharmacist.
“There are opportunities to catch things where the patient will say, ‘Oh, that was supposed to be changed,’ or, ‘I am supposed to take two a day now instead of one?’” Moore says.
If a potential error is noted, pharmacists contact the prescribing physician to verify any prescription orders.
Electronic prescriptions were introduced to reduce medication errors and have been said to increase adherence to first fill medications since their introduction.
In recent years, electronic prescribing systems have been embraced by most prescribers in the United States. According to a 2017 report from SureScripts, 77% of all prescriptions in 2017 were delivered electronically.
But while experts say it’s been a move in the right direction, electronic prescribing hasn’t eliminated medication errors. Electronic systems just pose different types of error-related problems, says Carter High, PharmD, director of legislative affairs for Best Value Pharmacies in Texas. “The downside is they are only as good as the people who put in the information on the other side.”