Medication errors: when pharmacy is closed

Medication errors: when pharmacy is closed

Collection:
Health Policy and Services Research
Series Title(s):
Pennsylvania patient safety advisory
Contributor(s):
Gaunt, Michael J.
Pennsylvania. Patient Safety Authority.
ECRI (Organization)
Institute for Safe Medication Practices.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2012
Language(s):
English
Format:
Text
Subject(s):
Drug-Related Side Effects and Adverse Reactions
Medication Errors -- prevention & control
Pharmaceutical Services -- organization & administration
Pharmacy Service, Hospital -- organization & administration
United States
Genre(s):
Technical Report
Abstract:
When pharmaceutical services are not available, the medication-use process can be more vulnerable to errors. Between June 2004 and September 2010, Pennsylvania hospitals submitted to the Pennsylvania Patient Safety Authority 519 medication error reports that implied an event occurred while the pharmacy department was closed. The most common types of medication errors reported included wrong-drug events, drug omissions, and prescription or refill delays. The predominant medications associated with these reports were warfarin sodium, hydration solutions, insulin, guaiFENesin, and vancomycin. The incorrect drug was retrieved from an automated dispensing cabinet or night cabinet in 82.3% (n = 130) of wrong-drug events. In 28.7% (n = 43) of drug omission events, the medication was not available to the nurse to administer, leading to an omission. Strategies to prevent errors when the pharmacy is closed include providing access to a limited supply of medications to be used for urgent medication orders, standardizing processes for accessing medications when the pharmacy is closed to reduce variability and opportunity for error, and establishing a forcing function error reduction strategy to make the allergy "reaction" selection a mandatory entry in the organization's order entry systems for prescribers and pharmacists.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
Extent:
1 online resource (1 PDF file (pages 11-17)).
NLM Unique ID:
101579304 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101579304