Healthcare Getting It Right : Medication Error Prevention

Medication errors are costly, preventable and a major component to keeping patients safe as they receive their care.

Healthcare has excelled with attention to medication errors as well as prevention initiatives. We’re getting a lot right.

World health and international healthcare partners do a fantastic job spotlighting medical errors. A 2017 international goal tp reduce medication errors by 50% within 5 years was commendable [1]. While the pandemic may have redirected resources, the pandemic also offered time to structure national to international health efforts. Setting a renewed goal should be tied to specific, actionable items, including definitions, standards for reporting, intervention categories, regulatory and pharmacy leadership and involvement beyond acute care. Additionally, comparison and international reports could tier high income and low and middle income (LMIC) focus. A high income country focus on bar code scanning [2] as well as LMIC focus on resource efforts [3-5] are country-specific and can be equally impactful. Steps to improve medication safety can be supported, regardless of technology or resource constraint, with foundations that international excellence has already established. Intervention planning has an opportunity to draw from, validate and appreciate the voices that have spoken up, such as the East African nursing team’s concerns related to patient safety and lack of overall healthcare infrastructure [6], or Malaysian maternal caregivers who reported no access to measuring devices [7]. All of this is possible because WHO and international partners have set the foundation.

FDA efforts to reduce potential medication errors are important. As international medical regulation continues to unite, the comparison and percentage of regulator recommendations, types of recommendations, and protocol to initiate the recommendations will be a welcomed contribution to patient safety [8]. This could also be an International Coalition of Medicines Regulatory Authorities (ICMRA) leadership opportunity [9].

International publications have taken strong action toward medication error prevention. It is unknown how issues and concerns highlighted[10-11] will be incorporated into strategic plans, however WHO guidance has made space for all [12]. The advancement of patient safety literature has not yet seen organization of high quality documents in a collective library. It would be helpful to have quality rankings to the literature, as well as flags on out of date literature where more up to date, relevant literature may apply [13] . All of these opportunities are possible because we have strong publication attention toward medication errors.

Improved epidemiology with medical error tracking and reporting continues to be a focus. The leveraging of technology and current reporting systems remains unclear. International alignment on these reporting systems also remains unclear. Definitions and minimal standards to the tracking could be standardized through world health efforts. A universal, clear and concise definition of the term “medication error” could support international efforts , for example [14]. Definition of harm could also be clearer This is especially noticeable when journals publish conflicting information, such as most medication errors have no negative consequences versus more than 25% of medication errors are severe or life-threatening [15-16]. Epidemiological expertise could also be tasked with quantifying the burden of medical errors. Future potential within current epidemiology improvements are exciting.

Epidemiological work on medical error tracking and reporting continues to expand. Standardized reporting helps organizations like the Institute for Safe Medication Practices (ISMP) with responsibilities as well. The collective efforts toward consumer safety improvements could be supported with robust data. Continued evaluation of home medical errors, accompanied by social service and caregiver metrics, would strengthen the value of the work.

ISPM and other fantastic organizations have dedicated resources and websites on medication errors [17]. The opportunity for these sites to interact with providers and pharmacy resources is here. The opportunity for international alignment of ISPM-related organizations could enhance standards for consumer safety.

Pharmacist professional responsibilities to medication errors are a key to patient safety. Professional organizations should be valued for their organization to medication safety. International work could align to identifying standards to interventions, as well as measures of impact of these interventions [18-19]. Pharmacy professionals could and should also be involved in reporting and error surveillance decision-making.

Primary care recommendations for patient and physician medication education are important [20] . Quality accreditation or oversight could also help standardize the outpatient setting, so that physician groups are held to minimal standards in patient safety. ISPM, for example, offers training and targeted focus for ambulatory care. There are many ways to assess training, set expectations and identify standards for outpatient culture. Therapeutic objectives [21] reviewed as part of the patient visit, for example, could include whether or not errors at home were discussed at the visit. Opportunities to reduce medication errors through primary care improvements are feasible, and recent attention to this has gotten it right.

Medication safety training is offered without barriers, such as the ISMP [22] training . How these trainings are offered internationally, and in what languages, would be an interesting addition to international reports. Training toward various healthcare settings, as opposed to the traditional response that this is part of a clinician’s training before degree, should add to the conversation.

Medication errors involving veterans are frequently studied and often rely on VA data. [23-26]. VA inspector work on specific medication errors are transparent and welcomed., as well [27]. The applicability of recommendations for one VA to all VAs, and improvement projects that can be designed across the VA, non-VA and MHS systems, are exciting prospects. Studies to examine non-VA and VA comparisons bring added depth[28], and continued work on transition and care coordination can target medication errors. Multi-disciplinary approaches are also important. A recent pharmacist intervention for VA-users at a non-VA care center [29], for example, ties error prevention across systems.

Public health has an opportunity to acknowledge veteran medication error prevention partners. For example, VA community health nurse work with medication efforts[30] may or may not be a component to the greater local community health work of the area. Partnerships and potential future public health responsibilities are an opportunity.

Military responsibilities to medical error prevention have been highlighted in recent government reports. GAO and government inspection details have highlighted serious gaps in DoD/DHA medication error management [31] . There is tremendous opportunity to align DHA, VA and civilian definitions, terms, reporting criteria and management metrics (therapeutic objectives, quantified harm, quantified burden) with implementation recommendations. There is also opportunity to tie reimbursement, contract terms and quality improvement expectations to the medication error prevention work. Additionally, there is opportunity to invite ISPM to any challenges specific to the MHS or VA. These opportunities are possible because of the outstanding focus already in place.

Caregiver involvement is critical to address medication errors, particularly for children, those with special needs and the elderly. Recent public health acknowledgement of the caregiving population [32] will only enhance the portfolio of work on caregiver medication errors[33-36].

This is an area where teamwork has tremendous opportunity, and teamwork has already demonstrated commitment.

Continued medical error prevention excellence creates continued opportunities for better healthcare.

Healthcare Getting It Right

Sunday, September 25, 2022

Medication Error Prevention

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