Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic

Studies have shown that up to 21% of prescriptions have one or more prescribing errors.  These errors not only create potentially harmful situations for patients, they also increase a pharmacist’s workload.  This problem is potentially due to the small amount of classes given in medical schools for therapeutics and how to write prescriptions.

This study was conducted at a family medicine clinic and observed twenty-four resident physicians and the prescriptions they wrote while conducting outpatient visits.  In the study, the rate of prescription errors for the resident physicians was observed before and after interventions to prevent these errors were put into place.  The interventions included a prescribing educational program, audits and feedback for prescriptions each resident filled and weekly newsletters that included the most common errors, examples of the errors, ways to correct the errors, etc.  These interventions were given for three months.  The assessments of the prescriptions occurred one year apart so that prescribing habits and seasonal illnesses would not differ.

The results of the study showed that overall prescription errors went down 4.1%, from 18.6% to 14.5%.  The study also showed that the pediatric prescription rates for the physicians who took part in the educational program were 36% lower than the error rates of physicians that did not participate.

I found this study interesting because I have firsthand knowledge of how many errors prescribers make.  Working in a retail pharmacy, I see these mistakes in all types of prescriptions.  While mistakes do happen, doctors are just humans, a lot of the mistakes could be prevented just by double checking the prescription and by knowing the proper way to write a prescription and proper dosing for certain medications.  These interventions only took three months and errors went down by over 4%.  Errors not only affect patients, but they also cause increase work for pharmacists and their staff and the doctors that eventually need to fix the mistakes.  By implementing interventions, a lot of time and frustration can ben avoided and patient safety can increase.

Winder, MB, Johnson JL, Planas LG, et al. Impact of Pharmacist-led Educational and Error Notification Interventions on Prescribing Errors in a Family Medicine Clinic. J Am Pharm Assoc. 2015;55(3): 238-45.

A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care

Each year, the United States emergency department treats up to 158,520 children for adverse drug effects. According to previous studies, up to 21$ of these are caused by medication errors. In this study, researchers performed a prospective intervention study in the University of Heidelsberg’s children hospital. 18 beds were systematically studied through a three-step intervention to prevent medication errors in the drug-handling processes.

Each step of the intervention was directed at different causes of errors. After three interventions, there was a significant decrease in the frequency of errors performed by the nurses, from 91% to 26%. There was also a decrease from 88% to 49% in the number of patients who were exposed to at least one medication error. It is evident that the three step intervention decreased the amount of medication errors in the hospital setting.

This study is important and interesting because while performing pediatric care, it is necessary to be certain of what medications the patient needs administered. Implementation of this three-step intervention in other hospitals around the world will decrease the amount of emergency visits children take. It is worth it in the end to take the extra precautions to reassure that the medication being administered to the patient is correct.

Niemann D, Bertsche A, et al. A prospective three-step intervention study to prevent medication errors in drug handling in paediatric care. Journal of Clinical Nursing. 2015;24:101-14.

Medication Errors in Cardiopulmonary Arrest and Code-Related Situations

Medication errors that occur during medical emergencies are not well documented. However, following their systematic review of the literature, Flannery and Parli report that medication errors may occur more frequently than anticipated. According to the authors, these errors occur at all stages of treatment from prescribing to administration.

According to the literature, prescribing errors during code-related situations account for 10.7 to 46% of medication errors. While verbal prescribing is discouraged by many organizations, it is often necessary during emergency situations. The authors discuss ways, such as repeating the verbal order, to reduce the likelihood of medication errors during the verbal prescribing process. In addition, according to the literature, errors in medication administration during code-related situations account for 28 to 57.6% of medication errors.

The authors also explore medication errors that occur during preparation, as well as those that result from medication mislabeling and make additional recommendations to reduce such errors. For example, to reduce mislabeling errors, they recommend using two different sized syringes to draw up two different medications. What additional recommendations would you make to reduce medication errors during medical emergencies?

Am J Crit Care. 2016;25(1):12-20.