Medication Errors
Rachel Balick
Keep an eye out in your practice for the top 10 medication errors reported to the Institute for Safe Medication Practices (ISMP) in 2019. The list appears in the January 16, 2020, issue of the ISMP Medication Safety Alert! Acute Care newsletter and can be accessed online at https://apha.us/ISMP2019Errors.
Tapped in
ISMP is a trusted nonprofit organization dedicated to the prevention of medication errors that offers tools—many updated in real time to reflect the latest information—and operates a trio of voluntary national error reporting programs. Errors can also be reported by phone.
“Everything’s held in confidence,” said Allen J. Vaida, PharmD, FASHP, executive vice president of ISMP. “We’ve had practitioners—and, more recently, consumers—report errors to us.”
ISMP gets reports in person, too. “We get invited to do presentations around the country and the world,” Vaida said. “Afterwards, practitioners come up to us and say, ‘Here’s something that happened to me.’ ”
ISMP also has a memorandum of understanding (MOU) with FDA’s Medication Errors Reporting and Analysis Division. ISMP shares with FDA the information it receives through the reporting program, withholding names if the reporters request it, and FDA shares errors it identifies through its MedWatch Program.
Word to the wise
To make the best use of ISMP’s top 10 errors list, pharmacists should stop to consider whether any of them have transpired at their practice sites. “They can ask, ‘Has this happened here in our organization?’ ” Vaida said. “Oftentimes, pharmacists [at other practice sites] may say, ‘Oh, my God, that happens to me once a week.’ But they’re not sharing that information.”
It’s sometimes hard to tell that a practice site is at risk of an error if it has never received reports of errors before.
“They may not have even known that an error had occurred, or they may have had numerous good catches by the pharmacist, the technician, the physician, or the nurse,” Vaida said. Once a site knows that an error has occurred or nearly occurred, or that it has occurred at other sites, it can explore how to prevent a recurrence.
Sometimes, especially with look-alike drugs, pharmacists could get in touch with a vendor to see if there is an alternative, apply an auxiliary label, or add a warning in the computer system.
“With other reports, they may discover that two medications get mixed up all the time. Maybe it’s because they appear next to one another on a drop-down screen,” Vaida said. “Well, let’s separate them.”
One key to preventing errors that can harm patients is to explore whether there is an error reporting program in place and if it is functioning properly. Organizational culture also plays a huge role. “People can’t be afraid to share errors,” Vaida said.
In an open culture, everyone in the organization can start thinking differently about error prevention and close calls. “They may look and say, ‘You know what, I pulled the wrong medication from the shelf.’ Or ‘I just entered the wrong medication. How did that happen?’ They should not be afraid to share that information.”
Stay connected to materials that ISMP, FDA, and other organizations release about error risks.
“We tell all practitioners that some of these errors may not occur all the time, but when they do occur, they could have dramatic consequences,” Vaida said. “By looking at external information, like what ISMP puts out, you get a heads-up rather than waiting for it to occur in your institution.”
In the community
Though many of the top 10 errors took place in a health-system setting, ISMP hears plenty from practitioners in community and long-term-care settings. Many errors involve brand-name extensions, when manufacturers release new combinations of OTC drugs that have been on the market for years.
“There’s diphenhydramine alone, or it may be diphenhydramine with acetaminophen in it. Or it may be diphenhydramine with some other medication in it—say a decongestant,” Vaida said. “[Patients] might be grabbing the wrong Benadryl off the shelf.”
Medication error risks are a bigger part of the conversation as patient safety issues have attracted mainstream attention. “We hear from pharmacists all the time that they’re overworked. They don’t have enough time. They can’t counsel patients,” Vaida said. “If enough of this information gets out, it may help get them support at a corporate level.”