Pharmaceutical Care To Prevent Medication Error Yulia Trisna Department of Pharmacy Cipto Mangunkusumo Hospital Indonesia “NHS faces 'potentially serious problems' from wrong prescriptions on the NHS.” Daily Telegraph 15/12/9 2 Medication misadventures (preventable) (unpreventable) Medication Errors ADEs B C ADRs D A (injury) (No injury) Bates DW et al. J. Gen Intern Med. 1995; 10:199-205 E Medication error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medicine is in the control of the health care professional or patient. National Coordinating Council for Medication Error Reporting and Prevention http://www.nccmerp.org medication errors Outcome Multidisciplinary Multifactorial Multidisciplinary : Physician Pharmacist/Pharmacist Assistant/Pharmacy Technician Nurse Administrator Manufacturer Patient/Family Multifactorial : lack of knowledge/skills substandard performance behaviour poor system Prescribing/ordering Transcribing Preparation/Dispensing Administration PATIENT Types of medication error • Illegible prescription • Wrong route • Wrong patient •Wrong labeling • Wrong drug •Wrong storage • Wrong dose • Omission • Wrong dosage form • Commission • wrong preparation • Expired drug • Duplication “Swiss Cheese” Model of System Error: Example Nurse didn’t check the dose Outocome: Therapeutic failure Pharmacist didn’t review the prescription Patient needs a drug Dr prescribed a wrong dose Pharmacist Assistant dispensed the wrong dose Adapted from Loyola University Health System Presentation Safety Science: Human Error, Quality and Patient Safety Committee, 2007 Barriers Physician Pharmacist/Pharmacist Assistant Nurse Patient ADE “Near Miss” Pharmaceutical Care What? How? • Patient-centered practice • Practitioner’s responsibilities to optimize patient’s drug therapy and improve QoL • • • • Assessment Identification of DRP’s Care Plan Follow up Type of DRP : Untreated indication Improper Drug selection Subtherapeutic dose Supratherapeutic dose Adverse Drug Reaction Drug Interaction Failure to receive drug Drug use without indication (Hepler & Strand, 1990) Aims of Pharmaceutical Care Effective Safe Drug therapy Improve QoL Economic Relations in drug therapy Symptoms related to disease or therapy Human or systematic error Drug therapy Van den Bemt, Drug Safety 2000;22:321-33. Opportunity For Error Pharmaceutical Care Medication History Taking Ward Round Medication Review/Reconciliation Drug Information Drug Therapy Monitoring Counseling Adapted by P.Thornton from J. Reason, 9/01 Opportunity For Error Pharmaceutical Care Medication History Taking Ward Round Medication Review/Reconciliation Drug Information Drug Therapy Monitoring Counseling Adapted by P.Thornton from J. Reason, 9/01 Activities • • • • • • Medication History Taking Medication Review Ward Round Drug Information Counseling Drug Therapy Monitoring Medication History Taking Drugs used prior to admission Drug allergy Adverse Drug Reaction Medication error Non compliance Drug Mismanagement Ward Round Medication Reconciliation To ensure accurate information on medications currently use To identify intentional and unintentional discrepancies To resolve discrepancies : COMMUNICATION ! Why Medication Reconciliation? Discrepancies : Admission 22 % Transfer 66 % Discharge 12 % Santell J. Journal of Qual and Patient Saf. 2006;32:225-9 Data JCAHO Medication Reconciliation in Hospital A/E Ward Clinic ICU Medication Safety Patient Safety Communication, Communication, Communication Standard Medication Management & Use (MMU) Joint Commission International (JCI) Standard 4: ME 5: Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners. ME 6: Initial medication orders are compared to the list of medications taken prior to admission, according to the organization’s established process. Standard 4.3: ME 3: Medication information is kept in the patient’s record or inserted into his or her record at discharge or transfer. Medication Review Drug Information Drug Therapy Monitoring • Identifies DRP • Gives recommendation Counseling •To ensure patient’s understanding regarding his/her medications, and enhance his/her compliance. Discharge Medications Medication Errors March-August 2013 Cipto Mangunkusumo Hospital wrong dose Frequency wrong instruction duplication illegible prescription Near Misses: 99.5% non adherence wrong drug wrong dosage form wrong amount of drug wrong patient no indication others 0 100 200 300 400 500 600 700 N= 1777 Collaborative approach Physician Pharmacist Patient Carer Other health professionals Information and Communication THANK YOU
