Cutting Medication Errors

  • Article by: Nancy Crotti
  • Star Tribune Sales and Marketing
  • April 6, 2011 - 11:37 AM

Is a 95-percent accuracy rate good enough? It might look that way on the surface, but when it comes to medication errors, it wasn't good enough for the pharmacists at Hennepin County Medical Center (

They won the Institute for Safe Medication Practices (ISMP) Cheers Award last fall for reducing medication errors among patients who were discharged to nursing homes. Now they are working on spreading their methodology to other patients, other area hospitals, around the country and internationally.

Preventing medication mistakes
Medication errors are usually the result of human mistakes, and are best prevented by having proper systems in place, according to Steven Meisel, a pharmacist and director of patient safety for Fairview Health Services. Meisel represents Fairview on the Minnesota Association for Patient Safety, an alliance of several area health systems that also recognized Hennepin's work in this area.

The Joint Commission, an independent health care accreditation and certification organization, requires hospitals to perform medication reconciliation before discharge of every patient, to make sure there are no duplications, omissions or other errors that would harm the patient, according to Bruce Thompson, Hennepin's director of Pharmacy Services. Traditionally, physicians have performed this task, Thompson said.

But an error on one patient's reconciliation caught pharmacists' attention and led them to review the entire system. The patient was being treated intravenously for an infection in the hospital, but wasn't prescribed an oral antibiotic to complete the treatment upon discharge and had to be readmitted.

Study results prove telling
Pharmacy Services conducted a study of nursing home discharges in in 2008 and 2009, and found that when pharmacists were involved, the readmission rate dropped by 47 percent for patients who were not seriously ill, to 5.7 percent, according to Thompson. "That made us very excited," he said.

The hospital then extended Pharmacy Services' involvement to the discharge of all nursing home patients, highly acute patients and uninsured patients. Pharmacy Services is now conducting a pilot study on extending its discharge involvement with patients who have congestive heart failure and behavioral health issues.

"We hope soon that we'll be able to say that we do this process for all patients," Thompson said. "We need to know the cost benefit. There truly is a quality benefit, but we need to stay in business as well."

Meisel urged health care workers who notice inefficient medication systems to speak up. "If they see that a system is failing them, don't wait until somebody gets hurt," he said. "Participate with leaders in helping to redesign. Help with solutions and … follow the procedures."

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