R E V I E W S & A N A LY S E S Medication Errors: When Pharmacy Is Closed Michael J. Gaunt, PharmD INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Pharmacists play a vital role in ensuring safe and effective medication use by reviewing medication orders before patients receive the prescribed therapy. However, because of the limited hours of pharmaceutical services in some hospitals, not all medication orders are prospectively reviewed by a pharmacist. For all U.S. hospitals, inpatient phar- ABSTRACT maceutical services are provided an average of 112 hours per week (Monday through When pharmaceutical services are not Sunday), or 16 hours per day, with smaller hospitals and health systems having fewer available, the medication-use process service hours per week than larger hospitals.1 An estimated 41.2% of hospitals provide can be more vulnerable to errors. 24-hour inpatient pharmaceutical services. This also varies significantly by staffed-bed Between June 2004 and September size, with larger hospitals more likely to provide 24-hour inpatient pharmaceutical 2010, Pennsylvania hospitals submit- services. For example, only 8.8% of hospitals with fewer than 50 staffed beds provide ted to the Pennsylvania Patient Safety 24-hour inpatient pharmaceutical services, whereas 98.4% of hospitals with 600 or Authority 519 medication error reports more staffed beds provide 24-hour inpatient pharmaceutical services. that implied an event occurred while The use of remote order entry and review technology that provides pharmacists with the pharmacy department was closed. real-time access to a patient’s medication profile, medical history, and other key patient The most common types of medication information can provide hospitals with access to a pharmacist 24 hours a day. A 2008 errors reported included wrong-drug survey of U.S. hospitals found that 20.7% of the hospital pharmacies that were not events, drug omissions, and prescrip- open 24 hours a day used an off-site pharmacist when the pharmacy was closed.2 The tion or refill delays. The predominant most frequent providers of remote order entry were affiliated hospitals (46.5%) or a medications associated with these regional or national company (36.8%). The other hospitals (16.7%) using off-site phar- reports were warfarin sodium, hydration macist review of orders had on-call pharmacists for this activity. solutions, insulin, guaiFENesin, and Provision of on-site 24-hour pharmaceutical services contributes to a more secure vancomycin. The incorrect drug was drug storage and distribution system. It also reduces the need for night cabinets, non- retrieved from an automated dispensing pharmacist access to the pharmacy, and access to medications stored in automated cabinet or night cabinet in 82.3% (n = dispensing cabinets (ADCs) without prior order review by a pharmacist. When the 130) of wrong-drug events. In 28.7% pharmacy is closed, a well-organized drug storage system can safeguard access to medica- (n = 43) of drug omission events, tions and thereby reduce the risk of medication errors or minimize adverse outcomes the medication was not available to should an error occur.3,4 Without safeguards in place, medication errors can occur, the nurse to administer, leading to an some with tragic outcomes,5 especially if non-pharmacists have complete access to the omission. Strategies to prevent errors pharmacy after hours. when the pharmacy is closed include providing access to a limited supply of During case-by-case analysis of events reported by Pennsylvania healthcare facilities medications to be used for urgent medi- to the Pennsylvania Patient Safety Authority, analysts found a number of medication cation orders, standardizing processes errors that were occurring when the pharmacy department was closed. Some of these for accessing medications when the events, such as patients receiving a medication to which they have a documented pharmacy is closed to reduce variability allergy, are typically intercepted when the pharmacy department is open. This article and opportunity for error, and establish- includes examination of medication errors reported to the Authority that occurred ing a forcing function error reduction after the pharmacy department was closed. Factors that contributed to the events are strategy to make the allergy “reaction” delineated where possible. Strategies to reduce the risk of error are discussed. selection a mandatory entry in the organization’s order entry systems for METHODOLOGY prescribers and pharmacists. (Pa Patient In order to categorize and retrieve reports in which reporters implied that an event Saf Advis 2012 Mar;9[1]:11-7.) occurred while the pharmacy department was closed, Authority analysts created the standardized monitor code “24h” that can be entered into the program database dur- ing case-by-case analysis. This monitor code and the phrases “pharmacy closed,” “night closet,” and “after pharmacy hours” were used to query the data to identify reports, trends, contributing factors, and risk reduction strategies. Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 11 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S AGGREGATE ANALYSIS definitive determination for each and FOCUSED EVENT ANALYSIS From events reported from June 2004 every medication. However, based upon through September 2010, analysts identi- the type of medications involved (e.g., Wrong-Drug Events fied 519 medication error events that antilipemic agents, vaccines, bisphospho- Analysts identified wrong-drug events as occurred when the pharmacy was closed. nates), it is unlikely they were all critical. the most frequently reported (30.4%, A breakdown of these events by harm Analysis of the event descriptions revealed n = 158) medication error occurring after score, which is adapted from the National that 60.3% (n = 313) of events originated the pharmacy had closed. The top five Coordinating Council for Medication in the administration phase, or node, of medications involved in wrong-drug events Error Reporting and Preventions harm the medication-use process (see Table 3). included products containing guaiFENesin index,6 shows that nearly 87% (n = 450) Nearly 12% (n = 62) of reports did not (10.1%, n = 16), hydration solutions (8.9%, of the events reached the patient (harm include sufficient information in the n = 14), insulin (7%, n = 11), carbidopa/ index = C to I). Only two (0.4%) of event description to determine in which levodopa (3.8%, n = 6), and ampicillin the events resulted in harm significant node the event originated. sodium/sulbactam sodium (3.2%, n = 5). enough to require additional treatment. The two most common medication error types identified through event analysis, Table 1. Top Five Medication Error Event Types (430 of 519) from June 2004 through specifically from the event description, September 2010 represented 308 (59.3%) of the 519 reports, with the most commonly repre- % OF TOTAL EVENTS EVENT TYPE NUMBER (N = 519) sented event type being wrong-drug events (30.4%, n = 158) (see Table 1). Drug omis- Wrong drug 158 30.4% sion reports represented the second-largest Drug omission 150 28.9 category of event types (28.9%, n = 150). Prescription/refill delay 57 11.0 Table 2 lists the top 10 medications Wrong dose/underdosage 35 6.7 involved in events that occurred after the Extra dose 30 5.8 pharmacy was closed. Four high-alert med- ications, drugs that bear a heightened risk of causing significant patient harm when Table 2. Top 10 Medications Involved in Events That Occurred After the Pharmacy Was used in error,7,8 appear in the top 10. The Closed (166 of 519) from June 2004 through September 2010 anticoagulant warfarin sodium, a high- % OF TOTAL EVENTS alert medication, was the most frequently RANK MEDICATION NAME NUMBER (N = 519) reported medication (4.4%, n = 23). Even 1 Warfarin sodium* 23 4.4% though only one anti-infective agent, van- comycin, appears in the first five of the 2 Hydration solution 20 3.9 listed medications, anti-infective agents 3 Insulin* 19 3.7 as a class were most frequently involved 4 GuaiFENesin 18 3.5 in events (23.3%, n = 121). Other classes of medications cited in reports include Vancomycin hydrochloride 18 3.5 cardiovascular (8.1%, n = 42), analgesic 6 Potassium chloride* 14 2.7 (7.1%, n = 37), anticoagulant (5.2%, 7 CefTRIAXone sodium 9 1.7 n = 27), and electrolytes (5.2%, n = 27). MethylPREDNISolone 9 1.7 When analyzing the reports, analysts ques- 9 CeFAZolin sodium 8 1.5 tioned whether or not it was necessary for the medications involved in the events to 10 Carbidopa/levodopa 7 1.4 be ordered and administered when the Levofloxacin 7 1.4 pharmacy was closed (i.e., were they criti- Metoprolol 7 1.4 cal medications that required immediate Morphine sulfate* 7 1.4 administration?). The lack of clinical and patient details in the reports prevents * A high-alert medication Page 12 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority Night cabinets and ADCs provide nurses push to the infant. The infant’s gentami- and contributes to medication errors.11 with access to essential medications dur- cin level rose to 590 mcg/mL but declined For example, see the following: ing off-hours in hospitals where 24-hour steadily over the next several days. Her A patient was ordered Robitussin® pharmaceutical services are not available. renal function continued to be normal after the pharmacy was closed. The This access helps reduce the risk of drug and the child survived. registered nurse supervisor removed omissions and delays but provides more An unsafe practice with the use of ADCs Robitussin AC from the Pyxis. The opportunity for errors. The incorrect is the use of overrides, which bypass safety patient received Robitussin AC. The drug was retrieved from an ADC or night features, including pharmacy verification, error was not caught until more than cabinet in 82.3% (n = 130) of wrong-drug in favor of gaining access to the medica- 24 hours later. The patient suffered events. Insufficient information was pro- tion.10 Slightly more than 8% (n = 13) of no adverse effects . . . vided to determine if storage or how the wrong-drug event reports indicated the drug names were listed on ADC screens The wrong insulin product was retrieved nurse retrieved a medication from an in 7% (n = 11) of wrong-drug events. contributed to the mix-ups. However, it ADC using the override function. has been noted previously in the Penn- Roughly 90% (n = 10) of wrong-insulin sylvania Patient Safety Advisory that the Forty-three wrong-drug events (27.2%) events involved products with suffixes as accessibility and variety of medications involved drug products available in part of the drug name (e.g., HumaLOG® available, as well as a potential lack of an different combination products or Mix 75/25TM, NovoLIN® R, NovoLIN independent double check of the original modified-release formulations that carry 70/30, NovoLOG® Mix 70/30). Other order to the obtained medication, contrib- the same name with different modifiers medications with names that have suffixes ute to medication errors.3 or suffixes. Forty-one of these 43 events were also cited in medication error reports. reached the patient. Products containing Examples of these include the following: In an event published by the Institute for the expectorant guaiFENesin (25.6%, Safe Medication Practices, a physician — Depakote® and Depakote ER n =11) were the most frequently involved ordered ampicillin 200 mg and gentamicin — Effexor® and Effexor XR® agents in errors involving drug products 5 mg intravenous (IV) push for a prema- available in different combination prod- — Sinemet® and Sinemet CR ture baby girl.9 The nurse misheard the ucts or modified-release formulations. — Vicodin® and Vicodin ES® second antibiotic order as gentamicin GuaiFENesin is available as a single-ingre- Similarly, look-alike names contributed 500 mg. Because the pharmacy had dient product and in various combination to wrong-drug events in roughly 5% (n = 8) closed for the night, a nursing supervisor products. Practitioners often refer to of reports. These events involved name pairs obtained seven vials of an adult concentra- these products using actual and contrived with look-alike names such as quiNIDine tion of gentamicin (80 mg/2 mL vials) names such as guaiFENesin, guaiFENesin and quiNINE; Solu-Cortef® and Solu- from a night cabinet. The pediatric con- DM (guaiFENesin and dextrometho- Medrol®; and cefuroxime and cefTRI- centration (20 mg/2 mL vials) also was rphan), guaiFENesin AC (guaiFENesin AXone. All of these events reached the available in the same night cabinet, but with codeine), and guaiFENesin DAC patient. For example, see the following: the nursing supervisor did not notice it. (guaiFENesin, pseudoephedrine, and She brought the gentamicin to the patient A patient was ordered quinine sul- codeine), relying on the different suffixes fate and needed the dose after the care unit where one nurse drew up 12.5 to differentiate the products. However, this mL of medication from the seven vials, pharmacy had closed. The nursing type of nomenclature is often confusing supervisor retrieved quinidine sulfate and another nurse gave the medication IV from the night stock for the patient, and the patient’s nurse then adminis- tered the wrong medication. Table 3. Node in Which the Event Originated (457 of 519) from June 2004 through September 2010 Drug Omission Events % OF TOTAL EVENTS Analysts identified drug omission events EVENT TYPE NUMBER (N = 519) as the second-most frequently reported Administration 313 60.3% (28.9%, n = 150) medication error occur- Dispensing 63 12.1 ring after the pharmacy had closed. The Transcription 50 9.6 drug classes most frequently mentioned in drug omission reports included anti-infec- Prescribing 31 6.0 tives (26%, n = 39), anticoagulants (8.7%, Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 13 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S n = 13), gastrointestinal agents (7.3%, n = 11), that the pharmacist is to be called for Thirty-two events were identified. More and electrolytes (6%, n = 9). High-alert initiation of protocol. The nurse did than 62% (n = 20) involved a patient that medications7 represented 21.3% (n = 32) of not follow procedure. was prescribed a medication to which all reported drug omissions; warfarin (7.3%, A patient was ordered morphine he or she had a documented allergy. n = 11), HYDROmorphone (2%, n = 3), PCA after the pharmacy closed. The Only one documented allergy was caught and insulin (2%, n = 3) were 3 of the top 10 nurse should have notified the super- before reaching the patient; 95% (n = 19) individual drugs involved in drug omissions. visor to call the on-call pharmacist to of events reached the patient, with one Overall, little detail was reported in the compound the drug. requiring additional treatment. Examples event descriptions as to what factor(s) reported to the Authority include the contributed to the drug omission. In Prescription or Refill Delay Events following: 28.7% (n = 43) of the reports, the medi- Analysts identified prescription or refill Order [was placed] for cefepime 1 cation was not available to the nurse to delays as the third-most frequently gram. First dose was not checked by administer. Some reports simply noted reported (11%, n = 57) type of medication pharmacist due to pharmacy [being] “not available” for the reason why the event occurring after the pharmacy had closed on nights. [Staff] used another medications were not available, and other closed. Similar to drug omissions, anti- patient’s dose. . . . The patient responses included reasons such as the infective agents (21%, n = 12) were more developed a rash because he is also nurse being unable to locate the medica- often involved in these events as any other allergic to Rocephin®, which is also tion and the pharmacy not delivering the class of drug. The high-alert medications a cephalosporin. medication before it closed. insulin (5.3%, n = 3), fentaNYL (3.5%, This patient is allergic to Cipro®. A breakdown in the transcription process n = 2), and warfarin (3.5%, n = 2) were This patient was ordered Levaquin®, was noted in 16.7% (n = 25) of the drug among the top individual medications which is contraindicated in patients omission reports. In 19 of these reports, involved in delays. allergic to Cipro. The medication was transcription did not take place after The primary contributing factor to these removed from the night room by the the original order was written or when events, like that for drug omissions, was nursing supervisor while the phar- copying from an old medication admin- the unavailability of the prescribed medi- macy was closed. istration record (MAR) to a new MAR. cation (17.5%, n = 10). For example, see Anti-infective agents, including levo- Analysts were unable to determine why the following report: floxacin, cephalexin, and azithromycin, these breakdowns occurred. were involved in over half (n = 11) of the Nursing needed Demerol® PCA Analysis of reported event descriptions during 11 p.m. to 7 a.m. shift when documented allergy events. Celecoxib, revealed that some staff failed to follow pharmacy is closed. The night cabinet ketorolac, and other analgesics accounted after-hours procedures in 14.7% (n = 22) was not properly stocked, so the phar- for another 20% (n = 5) of these events. of the reports. For example, in 6% (n = 9) macist had to be called in. of the reports, nursing staff did not call or RISK REDUCTION STRATEGIES attempt to call the on-call pharmacist for Prescribing Events Healthcare facilities can strive to identify assistance. This prevented the pharmacist One key service that the pharmacy pro- systems-based causes of the medica- from assisting in locating the appropriate vides is prospective medication order tion errors that take place when on-site drug or traveling on-site to prepare the nec- review. One aspect of order review is pharmacy services are not available essary medications (e.g., morphine syringe checking the patient’s medication and and implement effective risk reduction for patient-controlled analgesia [PCA] laboratory profile for wrong doses, docu- strategies to prevent harm to patients. pump). Even on-site resources were not mented allergies, and potentially serious Although many of the reports submitted accessed by nursing staff; in 4.7% (n = 7) of interactions. When pharmaceutical to the Authority did not explicitly reveal reports, the staff nurse did not contact the services are not available, either on-site all of the causes and contributing factors, nurse supervisor to obtain the medication or by means of remote pharmaceutical healthcare facilities may consider the strat- from a night cabinet or contact the on-call services, vulnerability is introduced into egies described below, which are based pharmacist. Some examples of failure to the medication-use system that can allow on a review of events reported to the follow after-hours procedures reported to prescribing errors to reach patients Authority, observations from the Institute the Authority include the following: more easily. for Safe Medication Practices, and recom- Vancomycin protocol was ordered mendations in the literature. Analysts examined events for those after pharmacy hours. Protocol states that originated in the prescribing node. Page 14 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority Pharmaceutical Services that require retrieval and administra- — Regularly analyze ADC override — Explore the possibility of establishing tion while pharmacy is closed. reports, requests for missing or on-site 24-hour pharmaceutical ser- — Separate and segregate products unavailable medications, and other vices. Health-system pharmacies have using bins and dividers to improve sources of data (e.g., voluntary error an obligation to review medication safe drug storage.3 For ADCs, con- reports, administration of rescue orders for appropriateness and safety. vert matrix drawers to drawers with drugs) to identify problems.18,20 Accrediting organizations, such as locking lids. For look-alike products, Discuss findings with pharmacy and the Joint Commission, recognize this consider purchasing one product of nursing staff to identify potential risk responsibility and require prospective an identified look-alike pair from a reduction strategies. review of medication orders except different vendor or clearly differenti- — Use auxiliary labels to differentiate in certain situations.12 ating the products.19 products with look-alike names or — If establishment of on-site 24-hour — Store essential neonatal or pediatric drug name suffixes in medication pharmaceutical services is not pos- medications away from adult medica- storage areas. sible, investigate the concept of tions, including in night cabinets, — Standardize the manner in which remote, or off-site, pharmacy order when 24-hour pharmacy service is drug names and descriptions are entry services.13,14,15 These types of not available.9 displayed to nurses, including in com- services allows for pharmacist review — Standardize processes for accessing puter systems, ADCs, and typed lists. of medication orders when the phar- medications when the pharmacy macy may be closed at night or on is closed to reduce variability and Allergy Information the weekends. The after-hours cover- opportunity for error. — Establish a forcing function error age is often provided by an affiliated reduction strategy, a technique that — Develop protocols or checklists to guide hospital, another hospital, or a eliminates or reduces the possibil- the practitioner as to when a supervisor regional or national company.2 ity of a medication error by guiding or pharmacist should be contacted to — Each morning, pharmacy staff the practitioner to take the correct assist in medication retrieval and prepa- should reconcile all medications action while making it impossible ration. Regularly review the after-hours removed from ADCs and night cabi- to do the wrong thing.21,22 Make the procedures with staff. nets while pharmacy was closed by allergy “reaction” selection a manda- — Limit overrides to urgent situations tory entry in the organization’s order comparing what was removed against when a delay in therapy would harm the prescribers’ orders.16 entry systems for prescribers and the patient.10,18,20 pharmacists.23 Medication Access and Storage — Incorporate an independent double — Test computer systems to ensure — Provide access to a limited supply check by another practitioner at complete allergy information crosses (e.g., types of medications, quantities, vulnerable points of the after-hours interfaces among systems and trunca- dosage forms, container sizes) of medication-use system.16 This would tion of information is avoided. medications to be used for urgent include when retrieving a medica- — Standardize locations (e.g., front medication orders.17 Carefully select tion from a night cabinet or via an of medical record, on top of order the drugs stocked according to staff override, as well as transcribing medi- forms, computer screens, assessment expertise and the typical patient pop- cation orders after pharmacy hours. forms) in which practitioners docu- ulation in each patient care area.18 — Develop a check system to help ment and retrieve complete allergy — Ensure that drugs stocked in patient ensure accurate cabinet stocking.10 information, including descriptions care areas and night cabinets are in Another staff member from the of any reaction.23 Alert staff to ready-to-administer, unit-of-use forms pharmacy or a nurse on the unit can always refer to these areas for reliable (i.e., not stored in bulk containers).3,18 verify accurate stocking by having the information. pharmacy provide a daily list of items — Determine those medications for — Provide prescribers, nurses, and added to the cabinet. Employing bar- which administration after pharmacy pharmacists with education and code technology during the stocking hours is not critical. Create a proto- tools on medication allergies.24 Focus process can also help ensure accuracy. col to guide practitioners to identify education on screening patients for non-critical medications so that they — Require periodic review by a pharma- the potential of a reaction, recogni- limit unnecessary distractions and cist or pharmacy technician of storage tion of an allergic reaction, treatment better focus on those medications areas throughout the organization.3 of serious allergic reactions, and Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 15 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S where to access important drug infor- that imply an event occurred while the when the pharmacy is closed is to explore mation such as common allergies, pharmacy department was closed. The the possibility of establishing on-site cross allergies, and combination drug predominant types of medication errors 24-hour pharmaceutical services or products that may have implications identified through analysis of the event remote, or off-site, pharmacy order entry with common drug allergies. descriptions are wrong-drug errors, drug services. Regular monitoring of medica- omissions, and prescription or refill tion retrieval when pharmacy services are CONCLUSION delay events. Prescribing errors primar- unavailable could unveil potential errors. In Pennsylvania, 519 medication errors ily involved the ordering of medications Employment of strategies to safeguard the have been reported to the Authority to which the patient was allergic. The storage and access of drugs can help pre- primary long-term goal to prevent errors vent errors and harm to patients. NOTES 1. Pedersen CA, Schneider PJ, Scheckelhoff from Internet: http://www.ismp.org/ medication errors in hospitals. Am J Hosp DJ. ASHP national survey of pharmacy Tools/highAlertMedications.asp. Pharm. 1993 Feb;50(2):305-14. practice in hospital settings: monitoring 9. Institute for Safe Medication Practices. 18. Institute for Safe Medication Practices. and patient edication-2009. Am J Health Verbal order spells near disaster. ISMP 2011 ISMP medication safety self assess- Syst Pharm 2010 Apr 1;67(7):542-58. Med Saf Alert 2002 Sep 4;7(18):2. ment for hospitals. [online] 2011 [cited 2. Pedersen CA, Schneider PJ, Scheckelhoff 10. Problems associated with automated dis- 2011 Oct 10]. Available from Internet: DJ. ASHP national survey of pharmacy pensing cabinets. PA PSRS Patient http://www.ismp.org/selfassessments/ practice in hospital settings: dispensing Saf Advis [online] 2005 Sep [cited 2011 Hospital/2011/pdfs.asp. and administration-2008. Am J Health Syst Oct 3]. Available from Internet: http:// 19. Drug labeling and packaging—looking Pharm 2009 May 15;66(10):926-46. www.patientsafetyauthority.org/ beyond what meets the eye. PA PSRS 3. Safeguarding the storage of drug prod- ADVISORIES/AdvisoryLibrary/2005/ Patient Saf Advis [online] 2007 Sep [cited ucts. Pa Patient Saf Advis [online] sep2(3)/Pages/21.aspx. 2012 Feb 6]. Available from Internet: 2010 Jun [cited 2011 Oct 3]. Available 11. Drug name suffix confusion is a common http://www.patientsafetyauthority.org/ from Internet: http://www. source of errors. PA PSRS Patient Saf ADVISORIES/AdvisoryLibrary/2007/ patientsafetyauthority.org/ADVISORIES/ Advis [online] 2004 Dec [cited 2011 sep4(3)/Pages/69b.aspx. AdvisoryLibrary/2010/Jun7(2)/Pages/ Oct 3]. Available from Internet: http:// 20. Institute for Safe Medication Practices. 46.aspx. www.patientsafetyauthority.org/ Guidance on the interdisciplinary safe use 4. The Joint Commission. Standard ADVISORIES/AdvisoryLibrary/2004/ of automated dispensing cabinets [online]. MM.05.01.13. In: Comprehensive accredi- dec1(4)/Pages/17.aspx. 2008 [cited 2011 Oct 10]. Available from tation manual for hospitals: the official 12. The Joint Commission. Standard Internet: http://www.ismp.org/Tools/ handbook (CAMH). Update 2. Oak- MM.05.01.01. In: Comprehensive accredi- guidelines/ADC_Guidelines_Final.pdf. brook Terrace (IL): Joint Commission tation manual for hospitals: the official 21. Cohen MR, Smetzer JL, Tuohy NR, et al. Resources; 2011 Sep. handbook (CAMH). Update 2. Oak- High-alert medications: safeguarding 5. Institute for Safe Medication Practices. brook Terrace (IL): Joint Commission against errors. In: Cohen MR, ed. Medi- Potassium may no longer be stocked on Resources; 2011 Sep. cation Errors, 2nd ed. Washington (DC): patient care units, but serious threats 13. Thompson B, Conrad G, Gum MO, et al. American Pharmacists Association; 2007. still exist! ISMP Med Saf Alert 2007 Oct ASHP guidelines on remote medication 22. Kohn LT, Corrigan JM, Donaldson MS. 4;12(20):1-2. order processing. Am J Health Syst Pharm To err is human: building a safer health sys- 6. National Coordinating Council for Medi- 2010 Apr 15;67(8):672-7. tem. Washington (DC): National Academy cation Error Reporting and Prevention 14. Levine S. Fourfold increase reported: Press; 2000. (NCC MERP). NCC MERP index for after-hours nurse overrides boost medica- 23. Medication errors associated with docu- categorizing medication errors [online]. tion error rates. Pharm Pract News 2005 mented allergies. Pa Patient Saf Advis 2001 [cited 2009 Sep 15]. Available from Dec;32:12. [online] 2008 Sep [cited 2011 Oct 10]. Internet: http://www.nccmerp.org/ Available from Internet: http://www. 15. Mango MD, Mabe DM. Remote order medErrorCatIndex.html. entry services: providing 24-hour pharma- patientsafetyauthority.org/ 7. Institute for Safe Medication Practices. ceutical care for small to medium sized ADVISORIES/AdvisoryLibrary/2008/ ISMP 2007 survey on high-alert medica- hospitals. Hosp Pharm 2011 Sep;46(9): Sep5(3)/Pages/75.aspx. tions: differences between nursing and 677-79. 24. Institute for Safe Medication Practices. pharmacy perspectives still prevalent. ISMP 16. Grissinger M. Dose confusion with phos- Topical medications and allergic reac- Med Saf Alert 2007 May 17;12(10):1-3. phorus-containing products. P T 2003 tions. ISMP Med Saf Alert 1996 Jun 5; 8. Institute for Safe Medication Practices. Jul;28(7):432. 1(11):2. ISMP’s list of high-alert medications 17. American Society of Hospital Pharma- [online]. 2011 [cited 2011 Sep 15]. Available cists. ASHP guidelines on preventing Page 16 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the most frequently The following questions about this article may be useful for internal education and reported medication error types assessment. You may use the following examples or come up with your own questions. involving medication therapy deliv- 1. Which of the following is the most frequently reported type of medication error ered when the pharmacy is closed. involving medication therapy delivered when the pharmacy is closed? — Recall contributing factors associated a. Drug omission with wrong-drug events that occur b. Extra dose after the pharmacy is closed. c. Wrong dose/underdosage d. Wrong drug — Recognize the most frequently e. Wrong dose/overdosage reported high-alert medications involved in errors when the phar- 2. The incorrect drug was retrieved from an automated dispensing cabinet (ADC) or night cabinet in 82.3% of reported wrong-drug events. macy is closed. Select the factor least likely to contribute to wrong-drug selection from ADCs or — Distinguish between effective and night cabinets when the pharmacy is closed. ineffective strategies to reduce the risk of medication errors when the a. Combination drug products that carry the same name with different modifiers b. Lack of a review of the patient’s documented allergies pharmacy is closed. c. The volume and variety of medications available d. Use of overrides to gain access to the medication e. Drug names that look alike 3. The predominant high-alert medications involved in medication errors when the pharmacy is closed included all of the following EXCEPT: a. Warfarin sodium b. Morphine sulfate c. Meperidine hydrochloride d. Insulin e. Potassium chloride 4. All but one of the following are effective strategies to reduce the risk of medication errors when the pharmacy is closed. Select the ineffective strategy. a. Create a protocol to guide practitioners to identify noncritical medications so that they limit unnecessary distractions and better focus on those medications that require retrieval and administration while the pharmacy is closed. b. Standardize locations in which practitioners document and retrieve complete allergy information, including descriptions of any reaction. c. Develop a check system to help ensure accurate ADC stocking. d. Standardize processes for accessing medications when the pharmacy is closed to reduce variability and opportunity for error. e. If using ADCs, organize stock using matrix drawers. 5. The patient was ordered quiNINE and needed a dose after the pharmacy department had closed for the day. The patient’s nurse asked the nurse supervisor to retrieve the medication from the hospital’s night stock. However, the nurse supervisor retrieved quiNIDine. The patient’s nurse then administered the incorrect medication to the patient. Select the appropriate strategy to help prevent this event from reoccurring. a. Use auxiliary labels to differentiate products with look-alike names or drug name suffixes in medication storage areas. b. Store essential neonatal or pediatric medications away from adult medications, including in night cabinets, when 24-hour pharmacy service is not available. c. Ensure that drugs stocked in patient care areas and night cabinets are in ready- to-administer, unit-of-use forms. d. Develop protocols or checklists to guide the practitioner as to when a supervisor or pharmacist should be contacted to assist in medication retrieval and preparation. e. Limit overrides to urgent situations when a delay in therapy would harm the patient. Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 17 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 1—March 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.