Drug Topics - November 12, 2007 - (Page 4)

4 DRUG TOPICS NOVEMBER 12, 2007 www.drugtopics.com REDUCING YOUR RISK Ken Baker What types of drugs are involved in errors? T he steps involved in reducing medication errors are relatively simple in concept. The difficulty comes in the application of the steps to everyday practice. The first step in quality improvement is the identification of where, when, and how errors may occur within the pharmacy. Identification involves the gathering of knowledge and information. In this installment, we will explore one example of how knowledge and information can be used in a simple, straightforward manner and how it can be used to reduce the opportunity for error. If a pharmacy can identify the drugs or drug categories that lead to a disproportionate number of its errors, the pharmacy can design a special process to use when dealing with these drugs. The first tendency is to make a rule directing that extra attention be given to every prescription, but, as indicated by the word extra, that approach will not work for an extended period of time. Instead, take the drugs identified as potential problems and fill prescriptions for these drugs slightly differently. First, identify the 15 to 20 drugs or drug categories to be given “extra” attention. Every pharmacy’s list of drugs that cause problems will differ, although some drugs will appear on most lists. For 30 days record the drugs involved in each prescription error in the pharmacy—whether a near-miss (did not reach the patient) or an error (did reach the patient). Involve every member of the staff in putting together a final list of 10 to 12 drugs. Add to this a list of drugs that in the event of a mistake are more likely to result in injury. If you do not have your own list, consider the following examples from Pharmacists Mutual data. In 2000, Pharmacists Mutual Insurance Co. looked at claims reported over the three-year period of 199699. Three years later, a Pharmacists Mutual subsidiary, PMC Quality Commitment, looked at a different set of data—actual mistakes, as opposed to claims, reported by pharmacies using the company’s quality reporting program to record near-misses and errors. Note the differences in the results. Ask why certain drugs are consistently in the list of drugs most often involved in claims but not in the list of the drugs most often involved in prescription mistakes. The most striking example is warfarin. Warfarin and others Warfarin, as every pharmacy student is told, is the drug most often seen in claims against pharmacists. That observation is backed up by the Pharmacists Mutual Claims Study shown above. Of all mechanical error claims (80% of all claims), 7% involve warfarin. Warfarin, however, does not appear in the second chart— the drugs most often involved in actual mistakes, including errors and near-misses. The absence of warfarin in the second graph (see next page) suggests that while mistakes involving warfarin are not as frequent as with other drugs, if a mistake does occur and it does reach a patient, that error is more likely to result in a claim. Warfarin appears most often in claims because a serious injury is more likely when an error involves warfarin. Warfarin is a narrow therapeutic index (NTI) drug, meaning the difference between the therapeutic dose and the “at-risk” dose is closer than that with other drugs. This is true of many of the drugs or categories in the claims study. There are, of course, other factors. The second step in designing a quality program is to use the information gathered in the first step. In insurance, we refer to this step as “developing techniques.” Techniques are developed from the information available to address the risk identified. A useful technique is one that is simple and practical. Making a list Using the information on drugs most frequently involved in claims or mistakes, compile a list of drugs for Graph: PMC Quality Commitment, Inc. http://www.drugtopics.com

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Drug Topics - November 12, 2007 Contents Drugs Often Associated with Errors Wanted: More Convers to Drug Decision Tools MSRA Takeoff Raising Alarm Bells U.S. Still Volnerable to Drug Counterfeiting Strange Rx Stories: Are You Stupid? Are Students a Squandered Opportunity The Week at a Glance

Drug Topics - November 12, 2007

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