Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme: Hospital Pharmacy Practice Today - Just How Good are We?

Patient Safety–Results from the Hospital Pharmacy in Canada Report

Patricia Lefebvre
Editorial Advisory Board
Hospital Pharmacy in Canada Report
Montreal, QC

Patricia Lefebvre presented results from the 2005/2006 Hospital Pharmacy in Canada Report that relate to the state of patient safety from the pharmacy perspective. She drew attention to a disturbing trend: In almost every area where safety outcomes or measures had improved, they had done so in response to a change in regulation or legislation. This data indicates an apparent failure of the profession to be proactive rather than reactive
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She outlined the in-patient medical management process and the place of pharmacy within it. Pharmacists play a key role in the monitoring and surveillance of ordering, pharmacy inventory and management, and administration.

Various data sources examined together reveal that most medication errors occur during prescribing, Lefebvre said. Comprehensive chart reviews to determine the initiation point of the error find that only 4% of medication errors take place during dispensing, while 56% occur in ordering. Moreover, Medmarx reports that a handful of drugs are responsible for most errors. Targeting these high-alert drugs would address 80% of medication errors. However, the report’s survey reveals a lack of significant improvement in standardizing and limiting the available doses of many high-alert medications.

The survey found that 80% of hospitals had a policy on disclosure of incidents to patients and their families, compared to 63% in the last survey. The frequency of recording the disclosure in patient health records increased from 81 to 91%. Almost all respondents had a medication incident reporting system, but only 12% allowed the use of medication incidents for performance reviews. This distinction is important because it indicates a decrease in blaming of individual practitioners, Lefebvre noted. While all these changes seem positive, it is important to note that they happened in response to changes in legislative requirements.

Similarly, usage of medication safety self-assessment increased to 71% but the improvement was mostly a response to its inclusion in the ROPs. Again, movement in the right direction only seems to occur with outside prodding, she said.

The survey also asked respondents to identify significant barriers to medication history-taking and medication reconciliation when a patient is transferred between levels of care or discharged. The results were as follows:

•	The facility has examined the desirability and feasibility but additional resources would be required: 34%
•	The facility has not yet examined the desirability and feasibility: 22%
•	The facility has examined the desirability and feasibility but there are not enough other supports: 13%

Significantly, only 20% take medication histories for all patients, while 78% take them for targeted patients, Lefebvre noted.

A review of data about the saturation of Computerized Physician Order Entry (CPOE) systems shows that CPOE is not an effective safety tool without clinical decision support. Yet only six sites reported having clinical decision support, and even in those cases, there was no interface with pharmacy. The data clearly shows that these small process points are likely to have the highest impact on safety, rather than CPOE and automation, Lefebvre said. Verbal and telephone orders are limited to emergency situations when the physician is physically unable to write a medication order in only 42% of responding institutions. Only 58% have a list of dangerous abbreviations that are not accepted. Pre-printed medication orders are being reviewed 87% of the time when they are in manual form but not nearly as often when CPOE and automated systems are in use.

There was improvement in the removal of both concentrated electrolytes and concentrated narcotics. These changes were in response to ROPs or health ministry directives, she said.

Lefebvre presented a summary on the proportion of time spent by pharmacists in each activity. Time spent on drug distribution had fallen slightly from 48% to 43%, while time spent on clinical services increased slightly from 38% to 41%. Unless more time is spent on clinical services, pharmacists will not have an impact on clinical safety, she stressed.

She recommended that participants review the Quality Chasm Report Series on preventing medication errors. It found that at least 25% of medication-related injuries are preventable. There is strong evidence for the effectiveness of CPOE with decision support and pharmacist participation in hospital rounds, she concluded. However, there is not yet evidence to support bar-coding or smart pump technology, even though there is a general belief that they will positively impact safety.