Drug Topics - August 4, 2008 - (Page 3) 3 REDUCING YOUR RISK Ken Baker, B.S. Pharm., J.D. To prevent drug errors, go to the source n Aug. 6, 1945, the Enola Gay dropped the world’s first atomic bomb on Hiroshima, Japan. The devastation was mind-bending and worldchanging. Following the attack, President Harry S. Truman warned Japan that unless it accepted surrender, the United States would continue to bomb “ until we completely destroy Japan's power to make war.” The framework of winning that war, not just by defeating the enemy but by eliminating the underlying roots of war itself, can provide a focus for where we as pharmacists need to start on the road to protecting our patients from medication errors. If you want to prevent medication errors, don’t work on preventing errors but on preventing the origin of the errors. Errors are the tip of an iceberg. Underlying the errors are a larger number of mistakes, most of which we rectify before they reach the patient. We prevent many of these “near-misses” through the skills and diligence of our pharmacists and technicians. Some potential errors can be caught through the implementation of best practices, such as the use of National Drug Code (NDC) verification at strategic points in our prescription-filling workflow. A few errors are prevented by sheer luck. If we want to prevent the largest number of errors, we must work on preventing the initial mistake from occurring. When we design a continuous quality improvement workflow, we have two goals in mind. The first is to prevent a mistake from happening in the first place. The second goal is to discover and correct any mistakes that were made in spite of our best efforts. We put in place best practices to ensure that if we did type the directions incorrectly into the computer, the mistake is noticed and corrected before it reaches the patient. In order to eliminate the mistakes before they become near-misses or errors, we must know what and how many mistakes we make. In order to know what mistakes we make, we must record them—all of them, including the near-misses. We need to know, at a minimum, where in the workflow the mistakes were made; what the mistakes were; and where in the process we caught the mistakes. Every system has its own vulnerabilities. We must understand what the vulnerabilities are in our pharmacy system. If the system tracks only errors, we cannot answer these questions and we will not discover our vulnerabilities until they have resulted in errors. In order to know if our quality efforts are successful, O we need to be able to answer two questions. First, did we reduce the number of mistakes made relative to the number of prescriptions filled? Second, did we reduce the percentage of mistakes that reached the patient, i.e., the relative number of errors as compared with mistakes? Based upon the answers to these two questions, every pharmaErrors are the cy should have two charts posted monthly. The first chart represents tip of an iceberg. our quality-related event (QRE) Underlying the rate. QRE is a phrase used to deerrors are a larger scribe the total of all near-misses and errors added together. All number of mistakes, mistakes are quality-related events. most of which we The QRE rate is obtained by directify before they viding the number of mistakes or QREs (total of near-misses plus the reach the patient. number of errors) for the month by the number of prescriptions filled for the month. The second chart is the pharmacy’s success rate. The success rate in this scenario is the percent of nearmisses compared with the number of total mistakes (QREs) made by the pharmacy for the month. These two charts represent how well the pharmacy’s quality system worked. In successive months the first chart should show a decrease in the relative number of mistakes made. The second should show an increase in the percent of mistakes caught before reaching the patient. You cannot post the charts, however, and you cannot know how well, or how poorly, your system works, without recording the number of total QREs. You can do more with QRE information than simply posting charts. With this information, you can discover vulnerabilities in the pharmacy system before they result in errors. This article does not constitute legal or consultative risk management advice. You should not rely on the information here or in any similar article for a plan of quality or for legal matters. Consult a risk management consultant or an attorney. THE AUTHOR practices law as an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. He also consults in the areas of pharmacy error reduction and risk management. For questions or citations and footnotes, he can be contacted at ken@kenbakerconsulting.com.
Table of Contents Feed for the Digital Edition of Drug Topics - August 4, 2008 Drug Topics - August 4, 2008 Contents To Prevent Drug Errors, Go to the Source Researchers Still Studying Impact of Glycemia on Heart Disease First Dementia Treatment Guidelines Released Drug Topics - August 4, 2008 Drug Topics - August 4, 2008 - Contents (Page 1) Drug Topics - August 4, 2008 - Contents (Page 2) Drug Topics - August 4, 2008 - To Prevent Drug Errors, Go to the Source (Page 3) Drug Topics - August 4, 2008 - Researchers Still Studying Impact of Glycemia on Heart Disease (Page 4) Drug Topics - August 4, 2008 - First Dementia Treatment Guidelines Released (Page 5)
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