Enhanced medication safety

Improving communicaation and instituting double checking protocols can

catch a host of medication.

Cerebyx versus celebrex versus celexa. The first drug is used to treat
seizures, the second to relice pain and inflammation, and the final one to
treat depression. Vasly different applications, shockingly similar names.
With a slip a written prescription or a misinterpretation at the pharmacy, a
patient may be taking something that is not needed and potentially
harmful

Health care practitioners are all too familiar whit this scenario. According
to the institute of medicines july 2006 report preventing medication
errors, medication errors haram an estimated 1.5 million people in the
united states each year, resulting in upward of 3.5 billion in extra medical
costs. Put into even more personal terms, every hospital patient may be
subjected to as much as one medication error each day. These shocking
statistics for a largely preventable problem.

Common medication safety issues

With more than 33,000 trademarked and 8,000 nonproprietary medication

names in the united states as of 2004, its no suprise that many drug
names sound and look alike. (see FDA consumer magazine, july/august
2005 ) nurses, pharmacists and other on the front lines may easily
confuse unclear prescription because of the similarity in name or
appearance.

This sort of miscommunication extends beyond similarly named drugs.

Using abbreviations and zeroes after decimal points creates additional
unnecessary uncertainties. Hardwriting (the penmanship of many
physicians is notoriously atrocious) often leaves things up for
interpretation

Given that noncommunication or miscommunication is to blame in many

common errors, the central person with whom health providers need to
communicate the patient should be the first priority. Many times, historical
infromation on the patient is inccomplete and does not include detailed
information on a patients allergies, previous diagnoses and la result, or
other medicines that are being taken, including vitamins, herbs and over
the counter medication. Collecting this information and cconsistently
reviewing it prior to making treatment decccisions will allow clinicians to
carefully consider potential contraindications and medical concerns.
In this same vein, points of trasition for oatiens yieled yet another set of
challenges for safe medication use. According to the healthcare
improvenment , up to 46 percent of medication errors occur when new
orders are written at patient admission ar discharge. Changing a patients
clinical status or transferring a patient introducces new caregivers and
creates the opportunity for misinterpretations or missed instruction

Finally, lack of information on a particular drug or outdated warnings can

also impede safe medication use. With so many drugs on the market, up
to date and clinically relevant drug information must be available to all
involved in the medication use process

Solutions for improving medication safety

Though, there are a wide range of concerns in relation to medication

safety, there exist a number of pratical solutions that can realistically be
implemented in any setting

Better communication, first and foremost, increased communication with

patients can drastically reduce medication errors. The key factor here is
that the conversatuons need to be twoway. Patients should not just listen
to health professionals; they should be actively engaged in their own
health care, question prescription recommendations and take
responsibility for making sure that caregivers know their health history.
Providers should spend a few extra minutes with the patients to teach
them about mediccation and to listen to patients questions about proper
use or side effects. See the figure below for suggested in patient
education.

Keeping records it;s also vital to maintain a recccord of a patientss

medication and to make sure todiscuss all pills or supplements he or she
takes-from vitamins and herbal remedies to over the counter drugs and
regular presccriptions. statistics from the institute of mediine show that ,
inany given week, morethan four five u.s adulth take at least one
medication (e.g prescription or over the counter drugs, vitamins, minerals
or herbalsupplements) and almost a third take at least five different
medication. To avoid those circumstances when a medication may need
additional monitoring or its use may be contraindicatied, it is critical to
know in detail what the patient takes at home

As preeviously mentioned, medication errors occur most commonly at

transitions. Creating a complate and accurate list of all medication the
patient is currently taking comparing it against the admission, transfer
and/or discharge orders when writing medication arders and
communication thoroughly about current medications with the next
provider af care as well as the patients are essential to reducing medical
errors in prescriptions and dosing

Involving the pharmacist. Another way to decrease medication errors is to

involve the pharmacist more activity in the patients care. A recent study
from u.s pharmacopeiafound that surgical patients face an increased risk
of harmfull medication errors due to a lack of comprehensive oversight of
medication. The conclusion of that report? Dedicate pharmacists to the
periperative units.even in a non perioperative setting, the pharmacist can
provide critical support in providing essential drug information, monitoring
patients response to medication, providing education ta patients on the
medications they take or making recommendations on medication
changes to optimize drug therapy

Double checking medication system should be designed to detect the

error befor it reaches the patient. High risk medications those medications
that the have the potentioal to cause serious patient harm if they given in
error may benefit an additional, independent doublecheck. An
independent double check means a second person goes through the
whole process independently, including drawing up the medication and
administering it to patient. Studies at the institute for safe medication
practices have shown that independent double check detect
approximately 95 percent of errors

The take away message for all health is this enhanced communication
between providers, patients and pharmacists is critical to reducing the
likelihood of medication errors. Communication among those health care
professional repensible for prescribing, administering, preparing and
dispensing, or monitoring medication is critical to optimizing treatment.
Leaders must inspire teamwork and open communication. Understanding
the value of communication pertaining to the use of medications and
fostering an environment that support excellent communication can
decrease the incidence of medication errors resulting harm to the patient.