CHECK, PLEASE!

May 21, 2001

Pharmacies are verifying Rxs more often to reduce med errors, according to an exclusive survey of R.Ph.s

 

COVER STORY

CHECK, PLEASE!

Pharmacies are verifying Rxs more often to reduce med errors, according to an exclusive survey of R.Ph.s

Make extra sure you're dispensing health, not harm. That could serve as the motto for pharmacies in the year since the Institute of Medicine (IOM) sent a wake-up call to the public and practitioners alike about the deadly toll drug errors take every year—as many as 7,000 in hospitals alone.

"We know very little about errors that occur outside the hospital," admitted Janet M. Corrigan, who directed IOM's landmark report, To Err Is Human, except that they "undoubtedly occur." Despite the lack of hard data for community pharmacies, prescription dispensing policies and procedures are changing there, too, in response to that report and the heightened interest in medical mistakes of all kinds.

An exclusive Drug Topics/Hospital Pharmacist Report survey found that, in the past 12 months, roughly 69% of the pharmacies responding—chain, independent, and hospital—now double- or triple-check prescriptions before they reach the patient. Two-thirds of the hospitals took steps to facilitate error reporting, the survey showed. Nearly half of the independents hired technicians to help prevent or reduce medicinal miscues. About 40% of the chain respondents said techs had been added and work schedules adjusted to reduce time pressures that they believe contribute to errors. In all, 69% of the respondents said they had instituted new procedures to prevent mistakes.

A "lack of time" prevents more than half of pharmacists from implementing more error-prevention procedures, the survey found. And, although almost all practice settings rely on software to alert them to allergies and adverse drug or dosing interactions, half of the respondents said they had experienced errors not detected by their electronic watchdog. Still, 93% believe the procedures they have put in place have been either very or somewhat effective in reducing or preventing mistakes.

For most, that seems to be the bottom line. It's up to them and the profession to improve a system where errors are rare and unacceptable. More than half do not believe reporting errors to state boards of pharmacy would be useful. By wide margins, they fail to see a role for federal or state governments. They oppose federal legislation that would require mandatory reporting of serious errors as well as voluntary reporting of less serious incidents.

Here then are some of the details and responses from nearly 500 volunteer members of the Drug Topics/HPR Council of Pharmacists. While these findings cannot be projected to the universe of pharmacists, we believe they nevertheless can provide a valuable snapshot for the profession as it strives to meet the challenge of making the dispensing process even safer in the face of an ever-growing number of prescriptions.

Awareness of errors

Nine out of 10 pharmacists surveyed said they were aware of what they considered to be a medication error in their pharmacy in the past year. The median was six, with hospitals recording 10 and community pharmacies five. Nearly half said that their error rate had remained unchanged, while 23% said the number had decreased, 20% said it had gone up, and 9% said they didn't know. The wrong dosage seemed to be the most frequent error reported, followed by the wrong drug given (see Table 1).

 

Table 1
Types of errors and frequency

Types of errorsOftenSometimesRarelyNever

Wrong dosage4%43%47%6%
Wrong drug given3295810
Wrong route of administration0103554
Failure to catch interactions2204830
Failure to catch contraindications1165231
Failure to warn patients of potential hazards2134836
Other12342429

 

In all, 84% of the hospitals, 67% of the chains, and 56% of the independents reported instituting new prevention procedures. By far, the most common new safety procedure instituted was double- or triple-checking Rxs before they are dispensed. About 80% of community pharmacies reported doing so (see Table 2).

 

Table 2
New error-reduction procedures implemented

 IndependentsChains
Require double or triple checks of Rxs before dispensing79%82%
Add technicians to minimize time pressure4641
Improve work environment4447
Simplify or eliminate unnecessary steps3721
Adjust work schedules to minimize time pressure2639
Reduce confusion of look-alike drugs2414
Reduce number of people involved in dispensing2313
Add R.Ph. staff to minimize time pressure2217
Facilitate error reporting1822
Rely on bar-coding837
Establish computerized M.D. order entry33
Implement electronic prescribing methods17
Other2230

 

"Two people double- and triple-checking Rxs two times prior to dispensing and a third time when giving to the patient" has been "very effective," said a Minnesota chain pharmacist. Another chain pharmacist uses a "touch" system. "If you force yourself to physically touch all three: the computer screen, the Rx itself, and the resultant label, your eye will pick up a discrepancy," he said. "You touch the drug, directions, strength.... It forces you to take another look at the data. Then touch the name on the Rx bottle for the correct drug."

Use of technicians

Adding pharmacists and technicians was another solution, although adding techs was far more likely. Virtually every hospital respondent uses technicians, as do 96% of the chains and 87% of the independents. As for their impact on errors, 24% of the chain users said they had helped "moderately," as did 22% of the hospitals and 16% of the chains. Many respondents welcomed techs as "another set of eyes." One chain pharmacist said, "Without techs there would be no way to process the volume of prescriptions that we do. However, techs do make more mistakes than more knowledgeable pharmacists."

Time constraints were cited by more than half of the respondents in all practice settings as a reason for "inhibiting" implementation of medication error-prevention procedures. About 60% of those working in chains and hospitals said inadequate staffing was a culprit, while about 30% each of the independents and hospitals mentioned "tight physical space."

A Georgia chain pharmacist said he'd "like to develop a plan to have the prescription looked at by at least three people before going out [but does not have] enough time or people." An independent said he needs "better separation from customers, so I don't get distracted ... need more space to allow for better double-check procedures." A California independent said he wanted to "prohibit telephone orders" because too often they're a distraction. He hasn't implemented the ban yet, "because it would be too much of a shock to the system."

Better than four in 10 survey respondents reported improving the work environment as a way to prevent errors.

And problems with the work environment were the main reasons respondents cited as contributing to medication errors in their pharmacies (see Table 3). Some 85% of the chain respondents said "work overload" contributed "a great deal" to errors. About 60% of the independents agreed, as did 68% of the hospital R.Ph.s. "Time pressures are the No. 1 reason for errors," said a chain pharmacist. "If the public would look at pharmacy as a profession instead of a fast food service (i.e., drive-thrus), there would be fewer errors." Also high on the list was "inadequate staffing"—78% of the chain workers thought that was a major contributing factor, compared with 61% of the hospitals and just 32% of the independents. Illegible prescriptions seemed to be less of a problem for independents (25%) than for chains (52%) or hospitals (42%).

 

Table 3
Contributing factors to an error—average rating*

Work overload

Inadequate staffing

Look-alike/sound-alike drugs

Failure to catch a technician’s errors

Similarity in packaging

Illegible prescriptions

Insufficient prescription information

Confusing/unclear labels

Lack of systemwide control policies or procedure

 

Technology reduces errors

Pharmacies use their information system software to help them prevent problems, and more than 90% of them detect allergies and adverse drug or dosing interactions. But only about two-thirds of the software overall can zero in on overdosing or wrong dosing errors. About half the hospital software can do so, compared with 86% for the chains and 60% for independents.

Other technology also is being deployed in the anti-error effort by about 23% of the respondents, more than twice as many of them being from chains and hospitals than from independents. Automated dispensing (46%) is the top choice, followed by bar-coding (31%) and robotics (15%).

The Drug Topics/HPR panelists believe internal documentation of prescription errors is useful in helping to prevent future errors (69%), but more than half (57%) disagreed or strongly disagreed with the notion that reporting them to state boards of pharmacy would help. Hospital pharmacists were the strongest skeptics (63%), but more than half of the community practitioners balked at reporting errors to boards of pharmacy.

"I think internal documentation helps prevent the same error from happening again, because the procedure can be changed or problem corrected," said a hospital pharmacist. "I think people are hesitant about reporting to the state because of the fear that they may lose their license." An independent put it more succinctly: "Most people are reluctant to hang themselves." A pharmacist practicing in a Nevada chain store asserted, "Every board knows errors are made, and they also know how terrible our working conditions are. Nothing's been done yet." A Mississippi chain pharmacist said information going to boards would be beneficial if it were "used in a constructive manner and not as any type of punishment."

No government involvement

The pharmacists surveyed also were leery of any new role for either the state or federal government in preventing medication errors as the IOM report suggested (see Table 4). While 42% of the hospital R.Ph.s agreed there should be "federal legislation to establish mandatory reporting systems on serious incidents," 35% disagreed. Less than a third of the community pharmacists were in favor of mandatory reporting. Federal legislation establishing a voluntary system for less serious incidents wasn't much more acceptable to chains and was even less so to independents.

 

Table 4
Recommendations from the 1999 IOM report

DisagreeAgree
Require mandatory reporting systems on serious errors44%33%
Require voluntary reporting systems on less serious errors3932
Create a National Center for Patient Safety within the Agency for Healthcare Research & Policy4026
Provide payer and regulatory incentives to improve safety practices1953
Develop a “culture of safety” within health-care organizations869
Establish new safety guidelines by accrediting and regulatory bodies3040

 

By overwhelming margins, pharmacists from all sectors rejected the idea that federal or state government had a "responsibility" to pass legislation that would prevent med errors. Eighty percent, led by the independents' 90%, said there was no federal responsibility. Similarly, chains (60%), hospitals (70%), and independents (78%) dismissed state responsibility.

"Preventing errors cannot be legislated," responded an independent. "Humans make errors. Humans can prevent errors." A chain pharmacist agreed: "Feds can't regulate human behavior. A pharmacist must be totally, absolutely correct on every single task of filling a prescription. It is an exhausting task in and of itself. This focus, total focus, can't be legislated."

A hospital pharmacist said, "You cannot devise a system that will totally eliminate human error. By no means can the federal or state government do this. Voluntary reporting, when used as an educational tool and in a positive manner is the only way to invoke reporting."

Michael F. Conlan

WHO ARE THEY?

Drug Topics and Hospital Pharmacist Report mailed 1,660 four-page questionnaires to members of their Council of Pharmacists in late March. Nearly 500 were returned by the cutoff date, for a response rate of 29%. The average respondent has been practicing for 23 years; 79% were male and 21% were female. Pharmacists at independent pharmacies comprised 36% of the respondents; at hospitals, 32%; and at chains, 29%.

 

Mike Conlan. CHECK, PLEASE!. Drug Topics 2001;10:37.