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T. O. C. | Foreword | Ed. Board | Intro.| Demographics | Clin. Services | Drug Info. | Drug Distrib.| Drug Purchasing
Human Resources | Medication Incidents | Benchmark Indicators | Pediatric Hospitals | Respondents | Worksheet


Medication Incidents – Special Interest Section
Janet Harding, Patricia Lefebvre

A medication incident is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Medication incidents may be related to professional practice, drug products, procedures, and systems, and include prescribing, order communication, product labelling/packaging/nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use .1

The 1999 Institute of Medicine (IOM) publication, To Err is Human, challenged the health care system to improve the safety of medication use.2 The report raised the awareness of health care professionals and the general public to concerns regarding patient safety as well as to the opportunities for improvement. Also addressed were the deficiencies of a punitive health care culture that traditionally blames individuals for error and therefore contributes to our inability to discover system problems that increase the probability of a medication incident occurring. The 2002 report of the National Steering Committee on Patient Safety, Building a Safer System: A National Integrated Strategy for Improving Patient Safety in Canadian Health Care3 reaffirms the need to build a safer Canadian health-care system.

This year’s survey collected information on medication incident reporting systems and reduction strategies as a topic of special interest. Our goal in collecting and sharing this information is to provoke further review of medication use systems in Canadian hospitals, and decrease the probability that a patient or health care worker will be harmed by a medication incident.

Reporting Systems

The Canadian Society of Hospital Pharmacists (CSHP) Standards of Practice state, “The pharmacy department shall participate in a medication incident and medication discrepancy reporting program, in accordance with the CSHP Guidelines for Medication Incident and Medication Discrepancy Reporting”4 Ninety-two percent of all respondents (Table G-1) reported use of a medication incident reporting system within their facilities. Seventy-three % (83/113) of these respondents used an internal reporting system while 25% (28/113) used external systems. Encon®, a system provided by a liability insurance company, was the most commonly reported external system. This trend was particularly noted in Ontario where almost half of the respondents (49%, 17/35) reported using Encon. Two hospitals reported use of an Institute for Safe Medication Practices (ISMP) system, which uses Analyse-ERR®, software developed jointly by ISMP (US) and ISMP-Canada, to facilitate the tracking and analysis of medication incidents within institutions.

Among hospitals reporting use of a medication incident reporting system, the external group data was most commonly made available to was the regional hospital group (22%, 25/113), followed by the hospital insurer (15%, 17/113) and the provincial hospital group (8%, 9/113). Of the nine respondents reporting to a provincial hospital group, six were from the Atlantic region. Seven respondents reported the data was available to other organizations, such as ISMP, and of these, six were from Ontario. This finding may be related to the fact the ISMP-Canada pilot project to test Analyse-ERR® was done in collaboration with Ontario hospitals. The low number of hospitals reporting to external organizations is similar to the U.S. experience where only 17% of hospitals indicated they report medication incidents to the U.S.P. Medication Error Reporting Program and 16% to ISMP5 . The fundamental purpose of externally reporting medication incidents is to learn from the experience of others and to implement improvements to the medication use system in order to prevent similar occurrences. A proposal for a national reporting system to facilitate this pro-active approach has recently been developed by the Canadian Coalition on Medication Incident Reporting and Prevention.6

Ninety-four percent (106/113) of respondents with a medication incident reporting system stated the system was required by their hospital and 26% (29/113) indicated the medication incident system was required by the hospital insurer. Although 12% (14/113) of the respondents reported that they were required to report to their provincial government, and 18% (20/113) reported the medication incident reporting form was mandated by the provincial government, these findings are inconclusive, since not all hospitals within the same province reported these requirements. An internal medication incident form, mandated by their hospital, was used by 84% (95/113) of the respondents with a reporting system.

Written hospital policy requiring staff to submit a report when a medication incident occurs was reported by 88 % of hospitals with a reporting system. Virtually all respondents (94%) with a reporting system indicated medication incident reports included the name of the person who reported the incident. Forty-nine per cent of non-teaching hospital respondents indicated the name of the person involved in the incident is stated on the form compared to 28% of teaching hospital respondents. The individuals who report medication incidents were identified to be nurses (99%, 112/113), pharmacists (95%, 107/113), physicians (21%, 24/113) and others (18%, 20/113), with the “other” category mainly specified to be pharmacy technicians. Physician reporting was more frequent in teaching institutions (34%, 17/50) than in non-teaching institutions (11%, 7/63). Seventy six percent of respondents with a reporting system indicated written hospital policy clearly defined medication incidents to be reported.

Prescribing errors detected in the pharmacy before a medication is dispensed were reported by 21% of the respondents with an incident reporting system, and 27% reported incidents that occur in the pharmacy and are detected during the final check by pharmacy staff. Reporting of both these types of incidents is more common in teaching hospitals and in hospitals with greater than 500 beds. Virtually all respondents with a reporting system (96%,) indicated medication incidents that occur before the medication is administered to the patient and are detected on the patient care area are reported. Similarly, 77% (40/52) of teaching hospital respondents reported general staff could use the medication incident reporting system to report events with the potential for harm compared to 58% (41/71) of non-teaching hospital respondents.

Reporting of “near-misses” and events or circumstances with the potential to cause harm provide valuable insights into the medication use system’s vulnerabilities and can guide improvement efforts. It appears many hospitals do not report such events, particularly those detected within the pharmacy. These organizations may be missing valuable information that could be used to proactively identify problems and potentially prevent medication incidents.

Underreporting of medication incidents can be expected if individual blame is the result. A non-punitive medication incident reporting system in which all individuals are expected and encouraged to report incidents without fear of punishment or reprimand can provide important information about the medication use system. This seemed to be the case for the 72% of respondents with a reporting system who agreed (61%, 69/113) or strongly agreed (11%, 12/113) with the statement that medication incidents are openly discussed by staff, without fear of reprisal. However, 27% (31/113) of the respondents disagreed or strongly disagreed, and 33% indicated medication incident reports could be used during performance assessment.

Two thirds of all respondents (68%, 84/123) indicated strategies had been implemented to increase medication incident reporting. Forty-six percent (56/123) used in-service meetings to promote reporting, 38% (47/123) communicated improvements resulting from reporting to staff, 16% (20/123) provided incentives to staff for reporting, 7% (9/123) modified appraisal instruments to reward reporting and 7% (8/123) ensured medication incident reports were non-discoverable (dependent on provincial legislation). The Institute for Health Care Improvement suggests organizations remove de-motivating aspects of error detection by publicly rewarding reports of error, granting immunity from punishment and establishing confidential reporting of errors.7

Eighty-five per cent of respondents with a medication incident reporting system reported disclosing medication incidents to patients and / or families. The requirement to inform patients of the occurrence of an unexpected event or incident which may effect their treatment and medical condition is a responsibility under the Code of Ethics for most professions. However, frank discussions of poor outcomes and disclosure to patients and / or families by health care providers may be hampered due to fear of legal consequences.

Twenty-nine percent (33/113) of respondents with a medication incident reporting system reported the medication incident report is a part of the permanent patient health record. Twenty-seven of these 33 respondents were from Quebec where this is required by provincial legislation. Provincial legislation also dictates whether an individual medication incident report can be subpoenaed for legal proceedings. Almost half of respondents (44%, 50/113) indicated they did not know if medication incident reports could be subpoenaed for legal proceedings. Following the same trend, 71% (60/85) of respondents with committees responsible for reviewing medication incidents, did not know if the reviews undertaken by the committee could be subpoenaed for legal proceedings.

Medication Incident Review

In the past, medication incident reporting was often highly fragmented. Incidents whose root cause may have been common to processes throughout the hospital were identified and dealt with in professional or departmental silos. A common reporting structure with a clearly identified central core, the multidisciplinary patient safety team, is a start to improving quality in the medication use system. Sixty-nine percent of all respondents (Table G-2) reported a formal committee responsible for the review of medication incidents. Thirty-two per cent of committees have been actively reviewing medication incidents for less than one year, 28% for one to three years, 13% for three to five years and 19% for more than five years. This trend towards the active review of medication incidents by committee is encouraging. The committees identified responsible for medication incident review included the P&T Committee (56%, 48/85), Pharmacy-Nursing (34%, 29/85), Risk Management (28%, 24/85), General Quality Committee (20%, 17/85), Medical Advisory Committee (16%, 14/85) and Medication Quality Committee (13%, 11/85). Thirty-one percent (26/85) reported other committees were responsible for the review of medication incidents. Most of the names of these other committees would suggest they are specific to safe medication practices. Membership on committees included representation from pharmacists (94%, 80/85), nurses (94%, 80/85), physicians (72%, 61/85), risk management (68%, 58/85), senior administrators (45%, 38/85), quality assurance (26%, 22/85), pharmacy technicians (21%, 18/85), information systems (12%, 10/85) and biomedical engineering (1%, 1/85). Some institutions have extended membership to board members, spiritual care managers, infection control officers, human resources, health and safety officers and union representatives.

Reported responsibilities of the committee included: reviewing medication incidents reported internally (91%,77/85), promoting medication use system enhancements (72%, 61/85), recommending policy and procedure for reporting medication incidents (68%, 58/85), responding to medication incidents resulting in serious harm (62%, 53/85), root-cause analysis of medication incidents (55%, 47/85), providing education sessions on medication safety (41%, 35/85), reviewing medication incidents reported in the literature (36%, 31/85) and self-assessment audits (31%, 26/85). One respondent cited an essential role in creating a culture of safety within their organization.

Thirty-five percent (39/113) of respondents with a medication incident reporting system in place (46% of teaching hospital respondents and 25% of non-teaching hospital respondents) calculated medication incident rates. The most common denominators used by those respondents calculating medication incident rates were doses (41%, 16/39), patient days (31%, 12/39), admissions (28%, 11/39) and paid hours – pharmacy technicians (8%, 3/39). Rates of medication incidents within an individual institution can be used to identify trends and opportunities for system improvement. However, the benchmarking of medication incident rates across the health care system or within an institution is discouraged. A medication incident rate based on voluntary reporting cannot be considered a measure of patient safety as it will vary, depending on the degree of prompt and systematic reporting of medication incidents within the institution8 .

Teaching hospital respondents were more likely than non-teaching hospital respondents to report information on internal medication incidents to general staff health care providers. Large hospitals (>500 beds) were also more likely to report this information than medium size hospitals (201-500 beds) and small hospitals (100-200 beds). Teaching hospital respondents were also more likely to report information regarding published medication incidents to general staff health care providers than non-teaching hospital respondents. Methods used to communicate information to staff included newsletters (42%, 52/123), in-services (38%, 47/123) and formal rounds (12%, 15/123). Bulletin boards, discussions at staff meetings, communication books on wards, hospital E-mail systems or hospital computer internal messaging systems and pharmacy intranet sites were also mentioned. Even though it is encouraging to see medication incident information being shared with general staff, there is ample room for improvement; close to half of all respondents did not provide information on internal medication incidents or on published medication incidents to general staff. Sixty-three percent (78/123) of all respondents received the newsletter of the Institute for Safe Medication Practices (ISMP), a publication containing valuable strategies for medication incident reduction.

The American Society of Health-System Pharmacists (ASHP) Medication-Use-System Safety Strategy document details job responsibilities and associated tasks of a medication-use safety officer as well as proposed membership for an effective medication-use-safety team9 . Twenty-one percent (26/123) of all respondents reported having specific positions dedicated to monitor medication incidents. Of the 26 respondents who reported specific positions, nurses filled the position in 35% (9/26) of cases and pharmacists in 23% (6/26). Fifty percent (13/26) of respondents listed others as filling the position, with risk managers most often cited. Pharmacist FTEs reported in this position ranged from 0.05 - 0.10, nurse positions varied between 0.05 to 1.00 FTE and others from .10 - 2.00 FTE. Responsibility for medication safety should be considered a routine part of pharmacy practice and the data indicates opportunity for wider pharmacist involvement.

Medication Incident Reduction Strategies

Selection Procurement and Storage

Packaging and labeling that is not clear, distinct and easily differentiated from similarly named or packaged products contribute to the risk of an incorrect medication being dispensed or administered. Label clutter, color, contrast, reminders and warnings, terminology, typeface and package design should be reviewed when purchasing and storing pharmaceuticals.10 Seventy-one percent of all respondents (Table G-3) reported the potential contribution of packaging and labeling to a medication incident was considered for purchasing decisions. Only 29% considered the same for formulary additions; 7% of small hospitals (100-200 beds), 25% of large hospitals (>500 beds) and 41% of medium size hospitals (201-500 beds).

Floorstock medications can be administered prior to pharmacist review of the medication order and patient profile. ASHP suggests floorstock be approved on the basis of two criteria: capability for harm and medical necessity for immediate access.11 Thirty-six percent of all respondents indicated additions to floorstock were reviewed against an approved set of defined criteria.

On July 24, 2002, the United States Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued six National Patient Safety Goals for 2003. One of the six goals is to improve the safety of using high-alert medications with the recommendation to remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.12 A recent death in Ontario, caused by the inadvertent injection of concentrated potassium chloride, and the resulting inquest, criminal negligence charges and media publicity, have educated the Canadian public.13 Only eight percent of all respondents reported concentrated potassium chloride was not available on nursing units. Thirty-one percent of all respondents reported it was available on less than 10% of nursing units while greater than half (54%) indicated potassium chloride concentrate was available on greater than or equal to 10% of nursing units. The frequently tragic consequences of administering concentrated potassium chloride, combined with the wide spread availability of pre-mixed intravenous potassium chloride solutions, makes this a patient safety initiative hospitals should strongly consider.

Prescribing or Ordering and Transcribing

Any chance of confusion regarding the medications a patient is to receive post-operatively can be avoided by requiring physicians to prescribe complete medication orders after general anesthesia. Orders to “resume all previous medications” are subject to interpretation and should not be accepted.14 Eighty-two percent of all respondents (Table G-4) indicated physicians were required to re-prescribe medications after a patient had received general anesthesia.

Pronunciation, dialects, accents and background noise contribute to the risk of a medication order being misunderstood, misinterpreted or incorrectly transcribed when an order is verbally communicated. Thousands of sound alike drug name pairs and easily misheard numbers complicate verbal medication orders. Sixty-four per cent of all respondents indicated verbal and telephone orders are limited to situations in which the patient is at risk for harm AND the physician is unable to physically write an order. Although the goal of eliminating verbal and telephone orders may become more attainable with electronic communication technology, it is unlikely verbal communication of medication orders will be totally eliminated. Therefore, all health care providers should be familiar with practices that encourage accurate and safe verbal communication.15 The problems associated with verbal medication orders are compounded when a pharmacist accepts a verbal order from a healthcare provider other than the prescriber. Ninety-four percent (49/52) of teaching hospital respondents reported a pharmacist sees the physician order (an original, direct carbon copy, fax or scan) before a medication is dispensed, most of the time, compared to 83% (59/71) for non-teaching hospital respondents.

Eighty-six percent of all respondents reported a formal process was in place to review and approve pre-printed medication orders. Seventy-four percent replied this process extended to infusion dosage charts and guidelines and 56% of all respondents indicated there was a process to review and approve physician order sets (i.e. for computer order entry). Physicians, nurses and pharmacists are inclined to accept pre-printed orders, infusion dosage charts and guidelines and physician order sets as correct. The tendency to question is decreased when healthcare providers assume orders and charts have been previously checked for accuracy. Although these examples of standardization are important tools for minimizing error, it is equally as important there is a process in place to ensure they can be used with confidence.16

Abbreviations have a long history of contributing to medication error.17 The potential for patient harm is well known if the u (units) in an insulin order is interpreted as a zero (0) or if QD (every day) is thought to be QID (four times a day). Goal 2 of the 2003 National Patient Safety Goals (JCAHO) is to improve the effectiveness of communication among caregivers with a recommendation to standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use. Only 23% of all respondents indicated they had a designated list of dangerous abbreviations that WERE NOT accepted in the institution.

Drugs used in chemotherapy are frequently associated with error due to the complexity and wide range of dosing regimens. One of the ways in which the risk of a medication incident can be decreased is to ensure chemotherapy orders specify both the dose according to body surface area or weight and the calculated amount18, to facilitate an independent double check of the dose calculation by nurses and pharmacists. Of those respondents providing adult chemotherapy, 76% (71/93) reported chemotherapy orders included the total dose as well as a mg/kg or mg/m2 dose. Small hospitals (100-200 beds) and medium size hospitals (201-500 beds) indicated this practice was in place to a greater extent than large hospitals (>500 beds). Teaching hospital respondents gave a positive response more often than non-teaching hospitals. There were 52 respondents who provided pediatric chemotherapy. Similar to the respondents providing adult chemotherapy, 79% of this group indicated orders for pediatric chemotherapy included the total dose as well as a mg/kg or mg/m2 dose. Small hospitals had a higher positive response rate than medium size hospitals and large hospitals. Non-teaching hospital respondents gave a positive response more often than teaching hospitals; the reverse of that seen for adult chemotherapy orders.

Computerized physician order entry (CPOE) has come to the forefront of initiatives that may significantly reduce the incidence of medication error and improve patient safety. Only nine respondents indicated CPOE was operational; all were teaching hospitals and represented 17% of all teaching hospital respondents. Seventeen respondents replied they had an approved plan in place to implement CPOE. There was no difference between teaching and non-teaching hospitals in this group, however an approved plan was reported by a greater percentage of larger hospital (>500 beds) respondents. No respondents from Saskatchewan or the Atlantic provinces indicated an approved plan to implement CPOE. A 2001 ASHP national survey indicated 4.3% of American hospitals had prescriber order-entry systems and not surprisingly, larger hospitals reported CPOE significantly more than smaller hospitals.19

Of the nine respondents with operational CPOE, three were interfaced with the Pharmacy Information System (PIS). Although the Canadian numbers are small, this contrasts to the ASHP survey that indicated approximately 75% of hospitals with CPOE had links that transferred data from the prescriber order-entry system into the pharmacy computer system. This may be related to the prevalence of hospital wide systems in the United States. The requirement to re-enter orders into the pharmacy computer is redundant and provides an additional opportunity for error. Information systems that allow the interface to occur should be considered an integral component of CPOE. Three respondents reported CPOE integrated with a computerized Clinical Decision Support System. The American survey indicated 91.2% of hospitals required pharmacists verify medication orders entered into CPOE before dispensing from pharmacy. Only four of the nine respondents with operational CPOE indicated a medication order entered via CPOE remained conditional until reviewed by a pharmacist. This finding may be explained by the type of orders that are re-entered into pharmacy systems from the CPOE and whether floorstock medications are included or not.

Preparing, Dispensing and Administration

Status hierarchies in healthcare can act to discourage other healthcare providers from questioning a physician’s orders.20 ISMP reports flawed communication, often precipitated by intimidation, contributes to approximately 10% of serious errors occurring during drug administration. They suggest institutions have a process clearly specifying the steps to be taken to resolve drug therapy conflicts.21 Fifty-three percent of all respondents (Table G-5) reported a written hospital policy providing nurses and pharmacists the right to refuse to act on a physician order on the basis of patient safety was in place.

Fifty-nine percent of all respondents reported patient allergy status was known prior to a medication order being dispensed from pharmacy most of the time and 34% reported it was known some of the time. Lesar et al have reported that 12.1% of prescribing errors occurring in a hospital were due to the prescriber failing to recognize a patient’s allergy to the prescribed medication class.22 This emphasizes the importance of a pharmacist review of the patient’s profile information for detection of potential allergic reactions prior to dispensing the patient’s medication.23

Checking the actual drug against the physician order (not against the patient profile entry or the computer generated label) before a patient specific medication is dispensed for the first time introduces a double check into the dispensing function. Seventy-eight percent of all respondents reported use of this check most or some of the time. The use of automated dispensing units in patient care areas would influence the response to this question.

Heparin, insulin, morphine and inotropes are considered high alert medications with the consequences of error often more severe than with other drugs. Standardizing infusion concentrations is one strategy that can help decrease the possibility of calculation errors.24 It has been implemented the most extensively for heparin, with 82% of all respondents stating a single standard infusion concentration is used in at least 90% of cases. The availability of pre-mixed intravenous heparin solutions has probably contributed to this wide spread practice. Fifty-four percent of teaching hospital respondents indicated a standard infusion concentration was used for insulin in at least 90% of cases compared to 39% (28/71) of non-teaching hospital respondents. Thirty-nine percent of all respondents indicated a standardized infusion concentration was used for morphine, with no appreciable difference between teaching and non-teaching hospital respondents. Sixty-one percent of all respondents indicated this practice in place for inotropes. Medium size hospitals (201-500 beds) reported the greatest use of single standard infusion concentrations for inotropes, morphine and insulin.

Vincristine for intravenous injection, dispensed in minibags, can prevent inadvertent intrathecal administration.25 Eighty-nine respondents reported the preparation of vincristine. Thirty-one percent (28/89) reported they prepared and dispensed vincristine in an intravenous minibag or infusion bag. Although other procedures may be in place to reduce the occurrence of this tragic medication incident, the use of forcing functions (it is unlikely the contents of a minibag would be administered intrathecally) should be seriously considered.

Monitoring

Eighty-three percent of all respondents (Table G-6) indicated defined monitoring criteria for the administration of patient controlled analgesia (PCA) had been established and implemented. Narcotics are considered high alert medications, as described previously, and defined monitoring criteria can decrease the risk of harm associated with errors in concentration, rate, drug and route as well as third person PCA activation.

In order to direct efforts to decrease occurrence of medication incidents and increase patient safety, the problems with drug products, work circumstances, procedures, pieces of equipment, etc, must be identified. Voluntary reporting of medication incidents and near misses is one method used to gather this information. Twenty-four percent (29/123) of all respondents reported using random observation to monitor the occurrence of medication incidents, 15% (18/123) reported the use of selective monitoring of laboratory tests, and 9% (11/123) indicated chart review based on the use of antidotes was used. Fifty-eight percent (71/123) of all respondents indicated no other methods were used to monitor the occurrence of medication incidents.

The availability of relevant drug information for all healthcare providers connected to the medication use system is an important element of reducing the probability of error. Drug information was reported as being provided to all nursing units where the drug would be used prior to it being administered by 87% (106/123) of all respondents for new drugs added to the Formulary if information was not listed in the CPS; by 79% (97/123) for non-formulary drugs if information was not listed in the CPS; by 83% (101/123) for investigational drugs; and by 77% (95/123) for drugs obtained by the special access program.

Bar coding has been identified as a technology that can be used to ensure the accuracy of medication administration, improve efficiencies within the medication use process and improve overall patient safety.26,27 Thirteen respondents, primarily from larger, teaching hospitals, reported bar coding was used in the medication use system. The most common application of bar coding reported was to verify stocking of automated dispensing cabinets. Bar coding was also used to return doses to inventory in the pharmacy, verify stocking of unit dose bins and verify drug selection prior to dispensing from the pharmacy. No one reported bar coding was used in the medication administration process, either to verify drug selection prior to patient administration or to identify the patient during medication administration. A 1999 ASHP survey reported 8.2% of institutions used machine readable coding. Similar to Canada, the majority of use was for drug processing and dispensing. Only 14% using machine readable coding indicated use for medication verification at the bedside and only 11% for documentation in the medication administration record.28 Standardized bar coding of all pharmaceutical product packages, including unit dose, would enable the broader use of this technology in the medication use system.

There were 114 respondents who indicated a pharmacy computer system was in use. Pharmacy computer systems were widely used to check for allergies (91% of respondents using computer systems), therapeutic duplicates (89%) and drug-drug interactions (88%). Fifty-two percent of non-teaching hospital respondents and 30% of teaching hospital respondents stated the pharmacy computer system was used to check drug-lab values (dose adjustments).

The capability of a computer system to issue maximum dose alerts automatically upon order entry is a valuable tool in decreasing the risk of error associated with human performance. One quarter of respondents with a pharmacy computer system indicated it was used to issue maximum dose alerts automatically upon order entry. Seventy-one percent (20/28) of these respondents indicated maximum dose alerts for adults, 68% (19/28) for pediatrics, 61% (17/28) for neonates and 50% (14/28) for oncology. Ten percent stated the pharmacy computer system tracked cumulative doses and was used to issue maximum cumulative dose alerts automatically upon order entry. The potential of pharmacy computer systems to contribute to improved patient safety seems to be underutilized. At a very minimum, systems should be reviewed for their ability to issue maximum dose alerts upon order entry for those drugs commonly used in neonates and pediatrics and all drugs used in oncology.

Summary

Unit dose medication delivery, centralized intravenous additive programs, pharmacy generated computerized medication administration records and progressive clinical services have demonstrated pharmacists are leaders in improving the safety of the medication use system. The exploding number of marketed drugs, the complexity of medication therapy, challenging human resource issues and changing environments within our institutions continue to provide us with opportunities for leadership in patient safety initiatives.

The systematic review of the deficiencies in our medication use systems is an important step in quality improvement and patient safety. Medication incident reporting is a valuable tool when used to detect medication use system deficiencies and guide improvement efforts. However, in order for this tool to be its most useful, healthcare providers must be willing to report medication error. A cultural change is suggested when close to one-third of all respondents indicate staff fear reporting medication incidents. Although it is encouraging to see an increasing number of committees responsible for medication incident review, only one-third of these committees reviewed incidents reported in the literature, an important element in pro-actively reducing medication incidents. The survey data indicates there are medication incident risk reduction strategies, published in the literature and suggested by organizations concerned with patient safety, that have not been extensively implemented in Canadian hospitals. The widely publicized hazards with concentrated potassium chloride and the potential safe strategy of using pre-mixed potassium chloride is the most notable example. The very limited use of bar coding and computerized physician order entry, system improvements that may dramatically enhance patient safety, was the domain of a few larger, teaching hospitals.

The data should incite pharmacists to accept the challenge to actively analyze medication use systems and work collaboratively with other health care providers to ensure those systems optimally provide our patients with the safest care possible.

References

1. American Society of Health-system Pharmacists
2. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
3. National Steering Committee on Patient Safety, Building A Safer System: A National Integrated Strategy for Improving Patient Safety in Canadian Health Care. 2002. http://rcpsc.medical.org
4.   Canadian Society of Hospital Pharmacists, Official Publications 2000, 5.8.1, page 15.
5.  Pedersen CA, Schneider PJ, Santell JP, Kelly EJ. ASHP national survey of pharmacy practice in acute care settings: Monitoring, patient education, and wellness – 2000. Am J Health-Syst Pharm. Vol 57 Dec 1, 2000. 2171-2187.  
6.  Canadian Coalition on Medication Incident Reporting and Prevention, A Medication Reporting and Prevention System for Canada – Business Plan. Sierra Systems 2002  
7.  American Agency for Healthcare Research and Quality: Making Health Care Safer: A Critical Analysis of Patients Safety Practices. www.ahcpr.gov/clinic/ptsafety/index.html accessed May 22, 2002. 
8.  The Institute for Safe Medication Practices. http://www.is,p.org/MSAarticles/HospEval2.html accessed May 22, 2002. 
9.  American Society of Health- System Pharmacists (ASHP) Center on Patient Safety. The Medication-Use-System Safety Strategy. Introduction and task analysis. 2001. 
10.  Cohen MR, ed. Medication Errors. Washington DC: American Pharmaceutical Association; 1999: 13.1 – 13.22 
11.  American Society of Health-System Pharmacists. ASHP Offers Hospital and Health-System CEOs Practical Recommendations for Improving Medication-Use Safety (January 2000) http://www.ashp.org/public/news/breaking/hrm_memo.html  
12.  Joint Commission on Accreditation of Healthcare Organizations. 2003 National Patient Safety Goals and Recommendations. (July 2002) http://www.jcaho.org/news+room/news+release+archives/npsg.htm 
13.  Wiley, Diana, Mistakes that Kill, MacLean’s, Aug 13, 2001: 38-40. 
14.  Cohen MR, ed. 8.16 
15.   Institute for Safe Medication Practices. ISMP Medication Safety Alerts. Instilling a measure of safety into those “whispering down the lane” verbal orders. January 24, 2001. Available at http://www.ismp.org/MSAarticles/VerbalOrders.html
16.  Institute for Safe Medication Practices. ISMP Medication Safety Alerts. Designing preprinted order forms that prevent medication errors. April 23, 1997. Available at http://www/ismp.org/MSAarticles/Preprinted.html 
17.  Institute for Safe Medication Practices. ISMP Medication Safety Alert. May 2, 2001. 
18.  Cohen MR, ed. 15.1 – 15.19 
19.  Pedersen CA, Schneider PJ, Santell JP. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing ---2001. Am J Health-Syst Pharm. Vol 58 Dec 1, 2001. 2251-2266. 
20.  Baker GR, Norton P. Making Patients Safer! Reducing Error in Canadian Healthcare. Healthcare Papers. 2001; Vol 2, No 1: 10-31. 
21.  Institute for Safe Medication Practices. ISMP Medication Safety Alerts. Frequent problems with medication systems noted in ISMP hospital evaluations. June 3, 1998. Available at http://www.ismp.org/msaarticles/hospeval1.html 
22.  Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997; 277: 312-17. 
23.  Canadian Society of Hospital Pharmacists. Official Publications 2000. Standards of Practice 5.1.5 
24.  Cohen MR, ed. 5.1 – 5.40 
25.  Trissel LA, Zhang Y, Cohen MR. The stability of diluted vincristine sulfate used as a deterrent to inadvertent intrathecal injection. Hosp Pharm. 2001; 36: 740-5 
26.  Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Prepared for Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services by the University of California at San Francisco – Stanford University Evidence-based Practice Center. July 20, 2001; 487 - 494 
27.  ASHP Government Affairs Regulatory Summary. ASHP Comments on FDA’s Initiative to Require Bar Coding on Drug Products. August 2002. Available at http://www.ashp.org/public/proad/regulatory/august_2002.html 
28.  Ringold DJ, Santell JP, Schneider PJ. ASHP national survey of pharmacy practice in acute care settings: Dispensing and administration –1999. Am J Health-Syst Pharm. Vol 57 Oct 1, 2000. 1759-1775.