ASHP urges hospitals to take steps to evaluate medication use systems
In the wake of a drug safety accident at Indianapolis' Methodist Hospital that killed two infants and left four others seriously ill, the American Society of Health-System Pharmacists (ASHP) called on hospitals to critically evaluate their medication use systems to help avoid dangerous or fatal errors. The problem occurred when the infants mistakenly were given an adult dose of the blood thinner heparin, 1,000 times the dose they should have received.
"We are not judging what happened in that situation," ASHP practice standards and quality director Kasey Thompson, PharmD, told Drug Formulary Review. "But we want to highlight all the interventions to be considered when hospitals are thinking through their own systems in response to that tragedy."
"Our hearts go out to the infants' families and the hospital staff involved in this terribly sad event," said ASHP executive vice president and CEO Henri Manasse Jr., PhD, ScD. "This should be a wake-up call for hospitals across the country to be absolutely certain that the right systems are in place to prevent medication errors. Mistakes such as these are nearly always the result of a systems failure. It's vital that a systems approach is used to evaluate and prevent medication errors, rather than blaming an individual."
ASHP said hospitals and health systems should conduct a critical and thorough self-examination of their medication-use systems, including how medications are stored, prescribed, prepared, dispensed, and administered. But the society cautioned that hospitals should never assume technology alone will prevent all errors or solve all problems with highly complex medication use processes.
Trained professionals must remain in charge
"The judgment of educated and trained health care professionals should always serve as the initial and final authority regarding the safety of the patient," Manasse said.
ASHP's recommendations say medication use in hospitals and health systems is highly complex and often includes more than 100 distinct steps, each of which offers numerous possibilities for error and patient harm. Methods of reporting, analysis, and follow-up should emphasize process improvement, establish a culture of safety, and avoid blame, the society says. Only through coordination of medication-use processes and error-reduction strategies can patient safety be improved.
ASHP's recommendations on reducing medication errors in hospitals and health systems include:
- Assign a pharmacist to lead an ongoing, interdisciplinary medication safety team of health care professionals that conducts a proactive and structured analysis of the medication use process in pediatric and neonatology settings and identifies high-risk areas where mistakes could harm patients.
- Perform a thorough analysis of all drug preparation activities in NICU and PICU with an acute review of processes where staff manipulate the concentration of manufacturer-ready packages before administration. This is especially critical when the manufacturer-ready package is 10% greater than normal dose ranges administered.
- Minimize the number of available concentrations of intravenous medications through organizational policy developed by the P&T Committee.
- Dispense medications used in pediatrics and neonates in ready-to-use (unit-dose) form prepared by the pharmacy. For critical care beds, 64.3% of hospitals dispensed 75% or more of injectable medications in unit-dose form. Ideally, all medications used in a hospital should be prepared and dispensed by the pharmacy in unit-dose form.
- Implement bar code bedside scanning technology. Bar code medication administration is increasing, with 9.4% of hospitals reporting implementation in 2005, compared with just 1.5% in 2002.
- Develop a standardized process, train staff, and routinely assess competency of staff on performing independent checks (double-checks) for all high-risk medications. That process should be used even if bar code bedside scanning is in place.
- Seek and use knowledge from other institutions that have solved similar problems.
- Always label medications with the drug name and strength. No exceptions to that rule should be made, especially if there are any intervening steps or interruptions between medication preparation and administration. That step also reinforces the need to read the drug label.
- Avoid placing look-alike/sound-alike products in the same matrix drawer of automated dispensing devices.
While a reported 71% of hospitals use automated dispensing devices for drug distribution, it is vital that the judgment of educated and trained health care professionals serve as the initial and final authority regarding patient safety. Of the hospitals using automated dispensing cabinets, 82.6% have pharmacists check the accuracy and integrity of medications contained in the automated dispensing cabinets either before or after medications are replenished. And 32% of hospitals required a two-pharmacist check before dispensing medication to high-risk groups such as pediatric patients.
"Most errors and patient harm occur as a result of poorly designed and managed processes in which medications are stored, prescribed, prepared, dispensed, and administered," ASHP says. "Diligent and ongoing efforts to continually identify and improve error-prone aspects of these highly complex and changing processes can drastically minimize potential patient harm. Many process improvements require substantial financial investments, which have a high rate of return if calculated in terms of avoided patient morbidity and mortality. Payers and insurers should give hospitals direct incentives to make these investments."
Local needs dictate what to work on
Asked if there are certain recommendations that are more important than others, Thompson tells DFR that they tend to be hospital-specific, dependent on what hospitals have already done. "Ideally, hospitals would do all of the recommendations," he says, "but realistically they will be looking at where their greatest needs are."
Thompson adds that hospital and health system pharmacy directors have the responsibility to work in an interdisciplinary fashion to ensure medication safety for their patients. "Pharmacy directors play a vital role in leading team-based efforts," he says.
Given that a lot depends on local conditions, Thompson still says some of the ASHP recommendations are "low-hanging fruit" that can be implemented with sufficient initiative and agreement but don't require financial resources. Included in that category are the recommendations to use standard concentrations and to be sure look-alike and sound-alike medications are separated in drug dispensing equipment.
Two other recommendations that all organizations could do without spending a lot of money, he says, are to be sure there are independent double-checks for all high-risk medications and to be sure that all medications are labeled.
[Editor's note: More information is available on-line at www.ashp.org. Contact Dr. Thompson at (301) 664-8663 or e-mail: [email protected].]
In the wake of a drug safety accident at Indianapolis' Methodist Hospital that killed two infants and left four others seriously ill, the American Society of Health-System Pharmacists (ASHP) called on hospitals to critically evaluate their medication use systems to help avoid dangerous or fatal errors.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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