Going Deep about How to Protect Patients from Medication Errors: A Team-Based Approach
Medication errors are a serious problem that can lead to life-long injury or even death. It may seem like an obvious way to protect patients, but many healthcare organizations are finding out the hard way that just implementing single-platform EMR systems is not enough.
Healthcare providers and pharmacists need to work in tandem with each other and the patient to provide optimal medication use. This process involves comprehensive data sharing requirements and training for all members of the care team so they know what information should be shared.
What is the importance of medication error prevention?
A medication error is defined as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention.
The keywords here are "preventable event". The healthcare staff is completely immersed in making difficult decisions in a routine way. As human beings, we need to rely on technology, processes, and teamwork to help make the best decisions for patients.
The FDA receives more than 100,000 reports each year from United States citizens about possible medication errors. Then it reviews the reports of medication errors and determines the type and cause of these missteps.1
Serious harmful results of a medication error may include:
· Death
· Life-threatening situation
· Hospitalization
· Disability
· Birth defect.
The GTMRx Institute states that the failure to ensure the appropriate use of medications comes with a tremendous human toll. Avoidable illness and death resulting from non-optimized medication therapy led to an estimated 275,000 avoidable deaths in 2016. The cost: $528.4 billion. That’s 16% of the annual $3.2 trillion in U.S. health care expenditures.2
So all healthcare providers are clear that it is important to prevent medication errors.
What are the most common errors in healthcare settings?
Providers know that medical errors create a significant public health problem posing a serious threat to patient safety. As EMR systems grow in both number and complexity, they are only as successful at preventing medication errors as the providers’ use of them.
Above all systems, we have users on the other side who insert information and make decisions to treat the patients.
There are two major types of errors:
a. Errors of omission occur as a result of actions not taken. Examples are not strapping a patient into a wheelchair or not stabilizing a gurney before patient transfer.
b. Errors of the commission occur as a result of the wrong action taken. Examples include administering a medication to which a patient has a known allergy or not labeling a laboratory specimen that is subsequently ascribed to the wrong patient.
Why a team-based approach and interoperability are essential to prevent errors?
The way to prevent medication errors is by using processes, teams, and technology altogether.
The entire team collaborates on the patient's care and makes decisions together.
The GTMRx Institute says Comprehensive Medication Management (CMM) addresses medication therapy problems, thereby improving medication-related outcomes.
The team’s efforts are rooted in a robust, data-driven record of the patient’s health and medical history. This information includes both clinical findings in combination with diagnostic results.
But to get this into this point, interoperability needs to occur. This means that healthcare information needs to adopt, implement and enforce data sharing requirements among the public and private sectors.
As an example, with Meditech, there are flexible roles-based desktops where pharmacists have all the right tools at their fingertips to efficiently and effectively manage daily activities.
From making sure patients take their meds properly to managing drug inventory and compiling reports—the desktop enables the pharmacist to do everything you need from one central screen.
The system can make an entire electronic interaction checking for all orders as well as centralized allergy management routines to look for potential clinical errors.
The EHR is a vital piece of the coordinated medication-related safety protocol and must work hand in hand with other tools and processes.
The HealthTech magazine summarizes the GTMRx Institute these five principles to achieve medication management reform:3
· A personalized, patient-centered, systematic and coordinated approach to medication use will optimize outcomes and reduce the overall cost of care.
· Aligning systems of care to integrate comprehensive medication management and engaging patients to ensure they are willing and able to take indicated, effective and safe medications will optimize outcomes.
· Immediate delivery system, payment, and policy transformation will streamline clinical trials and reduce costs of bringing drugs to market while enabling successful, broad-scale adoption of integrated CMM services.
· Access to advanced diagnostics with complementary and pharmacogenetic testing is essential to target correct therapy.
· Team-based, patient-centered care models that recognize appropriately skilled clinical pharmacists as medication experts who work in collaborative practice with physicians and other providers are required for success.
In summary, bringing technology like EMR into hospitals and healthcare organizations is essential to reduce medication errors. But, it needs additional steps to take this reduction to the next level.
At TRINEXUS, we are looking forward to supporting organizations get there!
1 Working to Reduce Medication Errors, US Food and Drog Administration.
2 Get the Medications Right: A Blueprint for Change, J GTMRx Institute, July 2020, P5.
3 Health IT Innovation Is Key to Medication Management Reform, by
Katherine Herring Capps, HealthTech Magazine