Medication Incidents – Special Interest Section
Janet Harding, Patricia Lefebvre
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.
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
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
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.
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
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
Incident Reduction Strategies
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.
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
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.
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.
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
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
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).
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.
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.
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