By definition, a medication error is a preventable event that may cause or lead to inappropriate medication use or patient harm. Medication errors may occur at any point in time from prescribing to the PACE pharmacy dispensing the medication to administration. The Institute of Safe Medication Practices (ISMP) estimates that 7,000 deaths occur annually in the United States from preventable medication errors. The reality of medication errors is that they are possible in all care settings, including the home. Two of the most challenging aspects of medication errors in the home setting—and faced by PACE pharmacy services providers—are detection and prevention. Medication errors are an important topic in PACE pharmacy because of the Level 1 reporting guidelines, which require quarterly reporting of medication administration errors. Reportable errors are errors without an adverse effect that occur due to a violation of a physician’s order. This includes errors made by the PACE organization, an individual or entity that is contracted with the PACE organization, or a participant or caregiver. Reporting includes the date, location, type, contributing factors, and actions taken.
PACE Pharmacy Services: Common Risks for Medication ErrorsIn the following paragraphs, we will review common risks for medication errors, focus areas for medication error prevention, and specific considerations for medication administration error prevention in the at home setting. As mentioned previously, medication errors can occur at any point in time from prescribing through administration of a medication. There are several common risks that have been shown to increase the potential for medication errors: Polypharmacy is potentially the strongest risk factor for medication errors. Nearly one-third of adults in the United States take five or more medications. This number increases as we age. The larger the number of medications that a patient is prescribed, the higher the potential for medication errors. Avoiding overprescribing and controlling the duration of therapy are two important considerations for keeping medication totals at an acceptable level. Health literacy is another common risk factor. It’s imperative for participants to have an understanding of what medications they’re taking, why the medications are being prescribed, and when and how the medications should be taken. Medication adherence and proper administration are less likely when participants don’t understand what they are taking and why it’s important for their health and well-being. High risk medications are an identified list of medications that can cause significant harm if used in error. This includes medications that may have dangerous adverse effects; look-alike/sound-alike medication that could be interchanged during the ordering, transcribing, or dispensing process; or Beers list medications, which may be potentially inappropriate for use in the geriatric population. Minimizing the use of medications in this group unless absolutely necessary can potentially reduce the risk for medication errors.
PACE Pharmacy Services: Focus Areas for Medication Error PreventionThere are five basic focus areas for medication error prevention, including:
- Prescribing/Ordering, which includes the prescriber selecting and dosing the medication appropriately for the participant
- Transcribing, which is getting the original order accurately to the pharmacy either verbally, in writing, or electronically. As we move to a more electronic and automated world, there are new considerations for accurate transcribing to consider.
- Dispensing, which is the PACE pharmacy interpreting and filling the order accurately and as written by the prescriber
- Administration, which could involve a nurse, participant, or caregiver. This includes taking the medication in the manner in which it was prescribed.
- Monitoring and Reporting, which is appropriately following up with the participant to check on progress and using skills to determine if medications are being taken properly. Early detection is important for preventing more severe issues.