Improving drug safety (2023)

number 531(Reaffirmed in 2016. Supersedes #331, April 2006 and #400, March 2008)

Committee for Quality Improvement and Patient Safety

This document reflects emerging concepts in patient safety and is subject to change. The information should not be construed as dictating a single course of treatment or procedure to be followed.

Background

In his report,Prevention of medication errors, the Institute of Medicine (IOM) defines amedication erroras "any error that occurred in the process of using the drug"1🇧🇷 Los ejemplos incluyen la dosificación incorrecta prescrita, la dosificación incorrecta administrada para un medicamento recetado o la falta de administración de un medicamento (por parte del médico) o de tomar un medicamento (por parte del paciente). La investigación muestra que hay al menos un error de medicación por paciente hospitalizado por día1🇧🇷 Studies indicate that 400,000 preventable drug-related injuries occur in hospitals each year, generating additional costs estimated at $3.5 billion.1🇧🇷 Many of the early studies identified rates of medication errors and adverse events in large academic hospitals; however, one study reported an adverse drug event rate of 15.0 per 100 admissions to the community setting, where most patients receive care.2🇧🇷 These results double the rate of adverse drug events identified in previous studies conducted in academia (6.5 adverse drug events per 100 admissions)3🇧🇷 Seventy-five percent of the adverse drug events identified in this study were classified as preventable.

Despite the improvement of technology in the healthcare environment, errors related to the use of medicines continue. In a study involving 10 North Carolina hospitals, researchers reported harm occurred in 18.1% of patient admissions. Among the causes of injuries, drugs are second only to procedures4.

Human factors inherently limit the safety of healthcare processes and contribute to medication errors. Factors such as fatigue, inattention, memory lapses, lack of awareness, miscommunication, use of poorly designed equipment, noisy work conditions, interruptions, and various other personal and environmental factors play a role. important. Researchers have found that communication errors are the most common contributing factor in medication errors and adverse drug events.5🇧🇷 The communication problems observed in this study included written and verbal questions. Examples of written communication problems included incorrect dosages or incorrect medications in written prescriptions or incorrect medications listed on patients' medication lists. Verbal communication problems observed included "misunderstood verbal physician orders, miscommunication between patients and pharmacists, and miscommunication between nurses and pharmacists regarding the correct medication or dosage."5🇧🇷 According to The Joint Commission, accurate and complete medication reconciliation, the process of comparing a patient's medication orders to all medications the patient is taking, can prevent a number of prescribing and administration errors.6🇧🇷 Leading patient safety organizations are focusing on improving drug prescribing and administration practices and have endorsed system enhancements, including automated and non-automated technologies to reduce harmful medication-related errors.

Research has shown that approximately 75% of all medication errors occur at the prescribing or administration stage.3🇧🇷 There are several types and causes of errors in the prescription of medicines, such as contraindications related to allergies that are not detected, inadequate pharmaceutical forms and administration of excessive doses.7 8🇧🇷 Medication prescription errors also occur from root causes, such as miswritten or misinterpreted handwritten prescriptions. Recent findings suggest that computer-generated incomplete prescriptions can also be riddled with errors, indicating that "implementing a computerized prescribing system without comprehensive functionality and processes to ensure meaningful use of the system does not decrease medication errors." .9.

The complexity of prescribing drugs is attributed, in part, to the number of agents, which has increased at an impressive rate. Prescription problems, such as garbled words, missing components, and inappropriate use of abbreviations, have been reported anecdotally for many years. The problem has been exacerbated in recent years by the influx of new drugs with similar names and sounds, making it difficult to interpret the prescription.10🇧🇷 Similarity, similar-sounding business names can also be problematic. The Institute for Safe Medication Practices issues warnings about similarities in drug names or packaging.

Broad-based strategies to improve drug safety

A key step in improving drug safety is for physicians and other healthcare professionals to become familiar with the drugs available to treat their patients. There are several ways to do this:

• Keep current drug references up to date and have these references available at the time the drug is prescribed.

• Understand the patient's condition and diagnosis and the indications for the medication being considered, including all alternative therapies.

• Consider conditions that may affect drug efficacy, such as dosages, route of administration, patient weight, renal and hepatic function, and other important patient characteristics, such as pregnancy.

• Understand potential interactions between a newly prescribed drug and other drugs already used by the patient, including over-the-counter drugs and supplements, as well as therapies being considered (including surgical treatments).

• Recognize the potential risk of high-alert drugs, those drugs that carry a high risk of causing significant harm to the patient if there is an error in the drug use process. Intravenous oxytocin has been identified by the Institute for Safe Medication Practices as one such drug.11.

Other strategies to improve drug safety include the following:

• Ensure that a patient's current medication continues, if applicable, at the time of hospital admission and that additional medication used during the hospital stay is compatible with the patient's current therapy regimen.

• Emphasize medication reconciliation during transition periods of care, including admission and discharge and follow-up in the outpatient setting.

• Provide relevant patient education on why the medication is needed. Pay attention to cultural or educational needs to ensure understanding and communicate the reasons for changes in a patient's medication regimen.

The fundamentals of safe drug prescribing include a focus on certain elements of the order, as follows:

• Medication prescriptions must be legible and must include the following components: name of the medication, dosage, route of administration, frequency (or rate), reason or conditions under which the medication is to be administered if prescribed pro re nata (p.r.n.) ; and weight and age of the patient (if relevant to dosing). Writing an incomplete drug prescription substantially increases the risk of medication error. The prescriber's signature and identification number must be included on the prescription.

• Zeros and decimal points. Misuse of leading decimals and trailing zeros can be dangerous. The adage “always lead, never follow” can help mitigate errors, which can lead to 10-fold or 100-fold dosing errors (for example, always write 0.1, never write 1.0).

• Standard abbreviations. The use of non-standard abbreviations is confusing and can contribute to medication errors if the abbreviations are not interpreted as intended by the prescriber. Most healthcare institutions have standardized lists of acceptable abbreviations. The Joint Commission also developed a list of "Do Not Use" abbreviations that was endorsed by the American College of Obstetricians and Gynecologists. Additionally, some organizations provide warnings about dangerous abbreviations and other drug safety recommendations on their websites.11 12.

• Pro re nata medication orders. When prescribing a drug, it is important to provide the reasons for administering the drug or the parameters for administering a p.r.n. dose. This is particularly useful for preventing errors with sound-and-sound-alike medications or for medications that need to be given as needed (eg, moderate to severe cramps rather than just p.r.n.).

• Verbal drug orders should be limited to urgent situations where written (or electronic) drug orders are not feasible. To ensure accuracy, verbal medication orders (in person or over the phone) should always be followed by a reading by the person receiving the order. The prescriber should ask the recipient to repeat the order back to the prescriber if he has not yet read it. Because many medications have similar names, it is also helpful to include the medication statement in verbal medication orders.

Interruptions can potentially result in medical errors. It is important that all team members eliminate or minimize interruptions to the nurse's medication preparation or medication dispensing process. Strategies such as distraction-free zones, do-not-disturb signage in medication preparation areas, and the use of colored vests worn by healthcare professionals during the medication administration process are examples of methods to alert colleagues to that do not interrupt health professionals while they are focused on tasks related to the preparation or administration of medications.

Using health information technology to improve drug safety

In 2009, the Health Information Technology for Economic and Clinical Health Act created an opportunity for professionals and hospitals to qualify for Medicare and Medicaid incentive payments if they implemented certified electronic health record (EHR) technology. acronym in English) that met specific objectives. As of 2011, healthcare providers and hospitals must demonstrate "significant use of a certified EHR" to receive these bonus payments. Among the Essential Measures of Meaningful Use, several goals are specific to medication management and include the following13:

• Maintain an active list of drug allergies.

• Maintain a list of active medications.

• Use computerized physician order entry for drug orders

  (Video) Improving Drug Safety through Quantitative and Translational Systems Toxicology—Part 2

• Generate and transmit electronic prescriptions for non-controlled substances

There are many information technology applications for drug safety. These include computerized physician order entry, electronic prescriptions, automated dispensing cabinets, barcoding along with an electronic medication administration record, and IV infusion technology (smart pumps). There is now evidence to support the patient safety benefit of each of these technology systems. Two technology-based strategies specific to OB/GYNs who are directly involved in prescribing and prescribing medications include computerized physician order entry and electronic prescribing.

Computerized Entry of Medical Orders

Computerized physician order entry refers to a computerized ordering system for medications, laboratory tests, and diagnostic tests. Health professionals enter orders directly into a computer system that ensures standardized, legible, and complete orders. To maximize its benefits, computerized physician order entry should include some levels of clinical decision support. A clinical decision support system is an “active knowledge system that uses two or more elements of patient data to generate case-specific advice”14🇧🇷 The system is generally designed to integrate a medical knowledge base, patient data, and an inference engine to generate case-specific advice. Computerized physician order entry has been reviewed and endorsed by the IOM, the Agency for Healthcare Research and Quality, the Leapfrog Group, the National Forum on Quality, the Institute for Safe Medication Practices, and the American Association of Hospitals.14 15 sixteen.

To meet the Stage 1 meaningful use criteria, qualified healthcare providers must demonstrate that more than 30% of their patients who have at least one drug on their drug list have at least one drug order entered through the computerized medical order.

Electronic Prescription

Electronic prescribing (also known as e-prescribing) refers to the ability of a prescriber to electronically submit an accurate, understandable, and error-free prescription directly to a pharmacy from the point of care.17🇧🇷 While electronic prescribing is a feature commonly found in computerized order entry systems and incorporated into many, if not all, electronic medical records, stand-alone electronic prescribing systems are also available. These programs can be accessed over the Internet and can be used with existing office computers or wireless systems. Similar to computerized provider order entry, electronic prescribing can contribute to patient safety by reducing the chances of accidentally writing illegible prescriptions or inappropriate dosages. In addition, the direct transmission of a prescription to the pharmacy, as well as the formulary checks that many systems can perform, have the potential to reduce phone calls from pharmacists seeking clarification.1🇧🇷 Research has shown that e-prescribing with direct transmission can reduce dispensing errors and therefore improve safety. In one study, the e-prescribing error rate for prescriptions transmitted electronically from a clinic directly to the pharmacy was half the clinic's initial dispensing error rate (PAG= 0.03), which involved generating the prescription with a computerized outpatient order entry system, printing it out, and delivering it to the patient18🇧🇷 The Stage 1 meaningful use criteria also includes a requirement that "more than 40% of all permitted prescriptions written by the qualified provider are transmitted electronically using certified EHR technology."13.

Computerized medical order entry systems are primarily beneficial during the ordering and transcription processes. Errors can still occur if clinicians ignore important and relevant alerts from the system. Both computerized physician order entry and many electronic prescribing systems are written with clinical decision support systems, a critical safety feature that alerts prescribers to potential drug contraindications, allergies, or illnesses prior to prescribing. Some clinical decision support features are comprehensive but not clinically relevant and therefore generate a large number of alerts (also known as popups) to which prescribers may become insensitive (also known as popup fatigue). Studies show that healthcare providers override 49-96% of these alerts due to clinical irrelevance19🇧🇷 Customizing drug alert systems to make them more clinically relevant, including alert levels and incorporating patient-specific data into clinical decision support software development, can help Maximize the use of clinical decision support systems.20 21.

There are great challenges in implementing automated systems technology. Such challenges can significantly affect adoption, effectiveness, or both. These challenges include cost of implementation, intuitive user interfaces, involvement of healthcare professionals in system design and integration into healthcare processes, healthcare professionals' resistance to change, increased of time and workload, fears of losing control over clinical care, and how the data will be used. , and the healthcare provider intentionally circumvents security features.

Studies have shown that acceptance of a clinical decision support system is significantly improved if healthcare professionals trust the system to help them better care for their patients, the system reminds them of something they may have forgotten, or provides information that was not previously available.22.

Patient education and shared decision-making to improve drug safety

Regardless of whether automated or non-automated systems are used as part of the drug prescription process, patients should be involved in the process as appropriate. Physicians must confirm with the patient that they understand the medical condition for which the drug is being prescribed. For example, the post-teach method is useful in determining retention and understanding of medication use by asking the patient to repeat their understanding of the information back to the health professional. Involving the patient in her own care can improve adherence, outcome, and patient satisfaction, as well as reduce opportunities for error. This requires the concerted effort of all members of the medical team, both inside and outside the hospital. Such education may take the form of oral communication or brochures that explain the use, dosage, expected benefits, and possible adverse effects of the prescribed drug. Patients should have ample opportunity to ask questions and reiterate, to the physician's satisfaction, their understanding of the proper use of their medications. Allergies must be well documented and reviewed with the patient. A list of other medications currently used by the patient should be documented, and the patient should retain a copy of this list for the patient's personal benefit and to show to healthcare professionals at each visit. Extending this education to family members who will assist the patient in the use of the medication can promote the correct use of the prescribed medication.

Conclution

Health professionals feel the urgency to reduce medical errors that occur as a result of their care. Obstetrician-gynecologists need greater vigilance over the medication use process when caring for both the pregnant woman and her fetus, as well as the post-reproductive woman with potential for increased comorbidities. Following these tips regarding medication safety will not only help reduce errors, but more importantly, create the awareness needed to provide safe care.

Automated healthcare technologies have perhaps the greatest potential to dramatically reduce the incidence of harm from medication-related errors. Equally clear is the fact that the effect of these technologies depends on the speed with which national standards emerge and the success with which they are integrated into well-designed care processes. In the meantime, non-automated methods can still be used to improve drug safety. The American College of Obstetricians and Gynecologists encourages healthcare professionals to continue to examine all aspects of drug safety, both in the hospital setting and in their offices.

Resources

The following list is for informational purposes only. Referral to these sources and websites does not imply endorsement by the American College of Obstetricians and Gynecologists. This list is not intended to be exhaustive. The exclusion of a source or site does not reflect the quality of that source or site. Please note that websites are subject to change without notice.

Centers for Medicare & Medicaid Services. Medicare Practical Guide to the Electronic Prescription (eRX) Incentive Program. Baltimore (MD):CMS;2011. Availablehttps://www.cms.gov/partnerships/downloads/11399-P.pdf🇧🇷 Consulted on April 2, 2012.

Fisherman, M.A. The National Patient Safety Initiative for Electronic Prescribing: Removing an Obstacle, Confronting Others, Drug Saf 2007;30:461–64.[Pub Med

Tamblyn R, Huang A, Taylor L, Kawasumi Y, Bartlett G, Grad R, et al. A randomized trial of the efficacy of on-demand versus computer-based medication decision support in primary care. J Am Med Report Assoc 2008;15:430–38.PubMed [Complete text]