Reducing Medication Errors

According to the Agency for Healthcare Research and Quality (the lead Federal agency charged with improving the safety and quality of America’s healthcare system), nearly 700,000 emergency room visits and 100,000 hospitalizations each year are due to adverse drug events.

An adverse drug event is defined as harm to any degree experienced by a patient due to a medication and can affect nearly 5 percent of all hospitalized patients. The Food and Drug Administration reports that there are approximately 1.25 million medication errors each year in the U.S.

Most importantly, these errors can lead to potentially devastating effects to patients and their families. Beyond this personal impact, there are economic consequences. A report by the Institute of Medicine in the late 1990’s estimated that adverse drug events cost the U.S. as much as $37 billion each year, with $17 billion of these costs due to preventable errors. Because of this, the drive for a safer medication use process has been a major initiative for hospitals and safety groups throughout the country.

Lompoc Valley Medical Center recognizes that medication errors can be a significant risk to patient well-being and have set a goal to reduce these errors to zero. LVMC’s Pharmacy Services and the Pharmacy and Therapeutics Committee of the Medical Staff have put in place many policies and procedures to achieve this goal.

Some of these items include designating a list of medications which have a high risk of causing harm, even when given as prescribed, as “High Alert.” Each medication has specific safety requirements. Many medications require nurses to perform independent double checks with another provider before administering the medication. We also monitor a patient’s laboratory reports to ensure the patient’s condition is appropriate for the ordered item and to detect any adverse events as early as possible.

In addition, LVMC has created a list of “Look-Alike/Sound-Alike” medications. These medications can be easily confused with each other due to similar looking or sounding names (for example Clonidine and Klonopin). These look alike/sound alike medications have warnings, as well as shelf stickers reminding providers to make sure the selected item is what is intended during ordering and administering.

Advances in technology continue to improve the safety of medication administration. Computerized ordering has removed the difficulty of reading a physician’s writing. We all have seen or heard the jokes about how bad physician writing is, but it is no laughing matter when a patient experiences an adverse drug event due to a misread order from the illegible script. LVMC has also added bedside barcode scanning so that nursing staff can scan the patient’s identification wristband, as well as the medication, before administering the dosage. This ensures that the correct patient is receiving the correct medication. As an example of what this involves, LVMC staff scanned the administration of 127,204 doses in 2016.

But medication safety steps are not just for the medical care provider. There are several things the patient can do to help make sure they don’t experience an adverse drug event. First, ask questions! Make sure the nurse or provider is explaining to you what they are giving to you and what it is for. If you don’t have diabetes but are being given a diabetes medication, you need to find out why before they give you that medication.

Second, make sure your home medication list is accurate. Carry it with you at all times and make sure family members know where you keep your list. LVMC provides free medication cards for anyone wanting to carry such a list. It is sometimes difficult for healthcare providers to know what medications a patient is on if they don’t know themselves, especially after-hours and in the middle of the night, but having an up-to-date medication list prevents confusion and can help your nurse or pharmacist get you the right medications at the right time.

Next, when you are being discharged, make sure you understand what medications you are supposed to be taking and/or which ones you are supposed to be stopping. Our pharmacists are available to go over your home medication list and answer any questions that you might have. Be sure to bring that discharge medication list with you to your next doctor’s visit.

Lastly, read all the information given to you and follow up on any section you don’t understand. Speak up if you have questions or concerns. It is important that you, the patient, are an active part of your healthcare team!