FIP Perspectives: Realising global patient safety goals requires an integrated approach with pharmacy at the core

Patient safety is becoming increasingly recognised as a top priority for action that requires a collective and coordinated response. The leading cause of harm or injury in health care systems is medication errors. As medicines experts, the pharmacy workforce plays a key role in minimising medication errors and mitigating the global challenge of patient safety. Pharmacists’ involvement in ensuring patient safety is crucial. Pharmacists are charged with the responsibility to ensure that when a patient receives and uses a medicine, it will not cause harm or death. The International Pharmaceutical Federation (FIP) recognises the critical role the pharmacy plays in realising global, regional and national patient safety goals; and works with its partners, stakeholders and members around the world to advocate for the role of pharmacy in achieving this global patient safety agenda and to envision a world of safe access to medicines and care.     

Preventing medication errors with smart infusion technology.

PURPOSE: Processes that pharmacists can use to identify high-risk areas and drugs that require special focus in error-prevention efforts are discussed, with emphasis on the need for i.v. medication error prevention. SUMMARY: Pharmacists can help determine where best to focus medication safety efforts and innovative technology by identifying areas that pose the greatest risk of harm to a patient, such as medications, administration routes, patient care areas, and diagnosis-related groups. Delivery of i.v. medications via infusion devices has traditionally not been a major concern for pharmacists. The introduction of "smart" infusion technology has changed that paradigm by requiring pharmacist involvement in defining minimum and maximum doses for continuous and bolus infusions used within a health care facility. This technology provides a software filter to prevent key-stroke errors in programming infusion devices for delivery of i.v. drugs, as well as a new source of data with which to measure medication errors at the bedside. Implementation of smart infusion technology at Vanderbilt University Medical Center appeared to prevent errors involving heparin. In addition to having an immediate positive impact at the bedside, the technology was relatively easy to implement. CONCLUSION: Smart infusion systems represent an innovative technology that can provide an additional layer of protection at the point of care to help avert i.v. drug errors and prevent patient harm.     

Prevention of medication errors: detection and audit

1. Medication errors have important implications for patient safety, and their identification is a main target in improving clinical practice errors, in order to prevent adverse events.
2. Error detection is the first crucial step. Approaches to this are likely to be different in research and routine care, and the most suitable must be chosen according to the setting.
3. The major methods for detecting medication errors and associated adverse drug-related events are chart review, computerized monitoring, administrative databases, and claims data, using direct observation, incident reporting, and patient monitoring. All of these methods have both advantages and limitations.
4. Reporting discloses medication errors, can trigger warnings, and encourages the diffusion of a culture of safe practice. Combining and comparing data from various and encourages the diffusion of a culture of safe practice sources increases the reliability of the system.
5. Error prevention can be planned by means of retroactive and proactive tools, such as audit and Failure Mode, Effect, and Criticality Analysis (FMECA). Audit is also an educational activity, which promotes high-quality care; it should be carried out regularly. In an audit cycle we can compare what is actually done against reference standards and put in place corrective actions to improve the performances of individuals and systems.
6. Patient safety must be the first aim in every setting, in order to build safer systems, learning from errors and reducing the human and fiscal costs.     

10 ways to improve medication safety in community pharmacies

Data sourcesNot applicable.SummarySince at least the time of Hippocrates, health care providers have recognized their responsibility to protect patients from potential harm resulting from the care they provide. In pharmacy, such harm typically results from a violation of any of the “5 rights” of safe medication use. However, a memorable adage stops short of providing operational guidance to improve medication safety. Specific actionable recommendations are needed to identify changes that, if implemented, would significantly improve the safety of medication delivery and use.ConclusionMost threats to medication safety result from weaknesses or failures in one or more of the key system elements identified by the Institute for Safe Medication Practices. Pharmacists should be advocates for implementing targeted recommendations to strengthen their practice systems and improve medication safety.     

Improving the safety of neuromuscular blocking agents: a statement from the USP Safe Medication Use Expert Committee.

PURPOSE: Recommendations of the interdisciplinary Safe Medication Use Expert Committee of the United States Pharmacopeia (USP) to assist health care professionals, manufacturers, and organizations in handling neuromuscular blocking agents (NMBAs) safely and effectively are discussed. SUMMARY: Review and analysis of the USP Medication Errors Reporting Program and MEDMARX program databases showed a continuing risk of patient harm or death due to errors with NMBAs. Medication errors involving wrong concentrations, wrong doses, wrong drugs, look-alike packaging, and sound-alike names, combined with lack of monitoring and communication, have been associated with the use of NMBAs in health care institutions. Serious adverse events occur when NMBAs are used without adequate safeguards. Recommendations for improving safety were developed through review and discussion of root causes and areas of concern with these medications. CONCLUSION: Medical errors with NMBAs continue to result in patient morbidity and mortality. Increased awareness and action on the part of all parties involved are needed to improve the safety of this class of medications.     

A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005-2010)

A review of all medication incidents reported to the National Reporting and Learning System (NRLS) in England in Wales between 1 January 2005 and 31 December 2010 was undertaken. The 526,186 medication incident reports represented 9.68% of all patient safety incidents. Medication incidents from acute general hospitals (394,951) represented 75% of reports. There were relatively smaller numbers of medication incident reports (44,952) from primary care, representing 8.5% of the total. Of 86,821 (16%) medication incidents reporting actual patient harm, 822 (0.9%) resulted in death or severe harm. The incidents involving medicine administration (263,228; 50%) and prescribing (97,097; 18%) were the process steps with the largest number of reports. Omitted and delayed medicine (82,028; 16%) and wrong dose (80,170; 15%) represented the largest error categories. Thirteen medicines or therapeutic groups accounted for 377 (46%) of the incidents with outcomes of death or severe harm. The National Patient Safety Agency (NPSA) has issued guidance to help minimize incidents with many of these medicines. Many recent incidents could have been prevented if the NPSA guidance had been better implemented. It is recommended that healthcare organizations in all sectors establish an effective infrastructure to oversee and promote safe medication practice, including an annual medication safety report. In the future, preventable harms from medication incidents can be further minimized by; the continued use of the NRLS to identify and prioritize important actions to improve medication safety, a central organization continuing to issue medication safety guidance to the service and better methods to ensure that the National Health Service has implemented this guidance.     

Using Smart Pumps to Understand and Evaluate Clinician Practice Patterns to Ensure Patient Safety

Background:

Safety software installed on intravenous (IV) infusion pumps has been shown to positively impact the quality of patient care through avoidance of medication errors. The data derived from the use of smart pumps are often overlooked, although these data provide helpful insight into the delivery of quality patient care.

Objective:

The objectives of this report are to describe the value of implementing IV infusion safety software and analyzing the data and reports generated by this system.

Case study:

Based on experience at the Carolinas HealthCare System (CHS), executive score cards provide an aggregate view of compliance rate, number of alerts, overrides, and edits. The report of serious errors averted (ie, critical catches) supplies the location, date, and time of the critical catch, thereby enabling management to pinpoint the end-user for educational purposes. By examining the number of critical catches, a return on investment may be calculated. Assuming 3,328 of these events each year, an estimated cost avoidance would be $29,120,000 per year for CHS. Other reports allow benchmarking between institutions.

Conclusion:

A review of the data about medication safety across CHS has helped garner support for a medication safety officer position with the goal of ultimately creating a safer environment for the patient.     

临床药师在骨科老年患者中的药物重整实践

目的:临床药师通过在骨科住院的老年患者中实施药物重整服务,识别和修正用药偏差,避免潜在的用药错误,从而保障药物治疗的有效性和连续性。方法:以2014年10月-2015年10月在某院骨科住院的60岁以上患者作为研究对象,由临床药师主导,制订患者的药物重整方案。结果:共获得625例患者的完整用药史,实施药物重整103例,药物重整共涉及491条药物医嘱,存在用药偏差232条,其中131条药物医嘱若不经处理可造成较为严重后果。药物重整患者中例均用药偏差(2.3±1.6)个,药师例均重整时间65 min。在用药不一致的种类中,以用药禁忌最为常见,重整的药物种类以心血管药物居多。患者自带药品数越多,发生用药偏差的可能性越大。结论:实施药物重整服务,可在药物伤害事件发生前有效地识别并修正用药偏差。医、药、护、患之间应加强沟通和交流,保障患者用药安全。     

Medication errors: prevention using information technology systems

1. Given the high frequency of medication errors with resultant patient harm and cost, their prevention is a worldwide priority for health systems.
2. Systems that use information technology (IT), such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records, are vital components of strategies to prevent medication errors, and a growing body of evidence calls for their widespread implementation.
3. However, important barriers, such as the high costs of such systems, must be addressed through economic incentives and government policies.
4. This paper provides a review of the current state of IT systems in preventing medication errors.     

关注抗肿瘤类高警示药品的用药安全

学习美国卫生系统药师协会最新发布的防范化疗和生物治疗的差错指南，结合我国日常工作，探讨从遴选药品到安全使用整个用药闭环各环节的警示点。用药风险不容忽视，优化和全面关爱患者需要团队参与服务。医疗机构、医师、药师、护士、生产企业和监管部门应各负其责，并加强沟通交流，多角度获取信息、了解潜在风险，提供专业技术支持和服务来提高用药安全性。抗肿瘤类药物无论是品种、剂型、给药方案都有其复杂性，有很多可能因疏失带来的风险，所以每个环节都要不断学习，持续改进，确保安全。     

Disclosure of adverse events and errors in healthcare: an ethical perspective.

Adverse events and medical errors affecting patient care are recognised internationally as major problems in medicine. The failure of health care professionals and health institutes to address this problem has threatened to undermine public confidence in the health care system as a whole. Less focus has been directed at the ethical issues raised by negative outcomes of care, specifically the issue of disclosure. Efforts to prevent negative outcomes of care must be supplemented by policies of increased honesty and openness with patients and their families about adverse incidents. Disclosure should be made easier, not riskier, for healthcare practitioners so clinicians can learn from mistakes and improve patient care. Ethical guidelines for error disclosure must distinguish between disciplinary action and reporting of adverse incidents. Disclosure of negative outcomes requires tact and good communication skills. Healthcare institutions should provide training for the clinicians in this area, if necessary. As a general rule, patients should be informed of unexpected adverse incidents as soon as possible. Medical staff should be rewarded for adverse event reporting and protected from institutional retaliation on account of errors made in health care.