Medication errors can be a big problem for healthcare providers. Patients being prescribed medication that conflicts with drugs they may be taking, but have not disclosed, is one of the biggest sources of these errors. The problem is this information may not come to the attention of healthcare professionals until it’s too late, according to a recent report produced by the ECRI Institute for the Pennsylvania Patient Safety Authority.
Almost 900 medication errors were reported in a seven-year time frame from July 1, 2004 through January 2011, and involved patients taking their own medications while in healthcare facilities. One or more controlled substances were involved in more than 40 percent of events reported to the PPSA with more than 25 percent involving high-alert medications. Oxycodone topped the list of patients personal medications implicated in medication errors — it was involved in 77 reported cases or 8.8 percent. Although the top five medications on the list are controlled substances, insulin accounted for 34 cases. Metropolol, used to treat cardiovascular disease, was listed in 25 cases.
Although larger healthcare facilities tend to have larger inventories of medications and have closed formularies, the report said, smaller community and rural hospitals do not necessarily have the room or funds to have a large inventory of medications and are more likely to allow patients to use their own medications.
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The authority outlined several ways providers can develop and implement standardized practices to reduce or eliminate these errors in its report. Here are 11 strategies healthcare providers can introduce:
Establish and follow a standard protocol
Use a screening method for patients admitted to the facility who have a previous history of bringing in their own medications.
Educate patients and families when patients are admitted to the facility about policies for patients’ use of their own medications.
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If there’s a conflict between a drug a patient is currently taking and what the physician wants to prescribe him, explain to the patient’s family why the medications are needed and encourage them to take the medications home.
If the facility does not need to use a patient’s medications, explain to the patient and his family the policy on bringing in prescription, over-the-counter and homeopathic medications into the facility.
Review medication administration records to understand how the directions for a patient’s own medications are described. For example, some organizations simply state “use home meds” on the records, which doesn’t reflect the actual dosage or frequency of administration for those medications.
Determine if the patient should be allowed to self-administer his own medications. For example, stating that if a patient’s home medication must be used, it should be administered by a nurse.
Explain to the patient and family the policy on bringing in prescription, over-the-counter and herbal or homeopathic medications into the facility.
Develop a process to ensure the proper labeling of any patient’s personal medications that are allowed for use in accordance with state regulations, making sure that the medications are identifiable, in good condition and not expired.
Tracking systems
Use a documented tracking mechanism to communicate the use of patients’ personal medications, especially when patients bring in controlled substances or investigational medications.
Before medications are sent to the nursing unit, place stickers or some other means of notification on containers for the medications that have been reviewed by a pharmacist.
Ensure procedures are in place to return patients’ personal medications before discharge, and note the final disposition of the medications in the pharmacy records.
The Harrisburg-based Pennsylvania Patient Safety Authority was created by the Commonwealth of Pennsylvania in 2002 and is an independent state agency.
