Drug Topics - December 8, 2008 - (Page 3) Clinical what happened in the steps before were correct. Take 5 is simple and it works. Since that first time of introducing Take 5 as a risk management technique, its use has expanded and it has become a pharmacy best practice. The National AlREDUCING YOUR RISK Ken Baker, BS, JD liance of State Pharmacy Associations (NASPA) has a CQI quality assurance program that uses Take 5 in three places in the prescription workflow. A psychologist at the University of Cincinnati estimated that each time such a best practice is used it will catch up to 95 percent of the mistakes that occurred before that step. Using this technique three times before a prescription reaches a patient, Rita had trouble sleeping and was depressed. greatly reduces the chance of this type of error slipping She visited her doctor and got a prescription for amitriptyline 10 mg. Her doctor wrote the through, although theoretically the possibility of an error reaching the patient is still not eliminated. directions very legibly: “iii hs.” Rita took the prescripThe final pharmacy quality check area is one of the tion to her pharmacy, dropped it off, and returned places in the NASPA Pharmacy Quality Commitment an hour later to pick it up. When she got home, she workflow where Take 5 is added as the first step. Not opened the bag and read the directions: “Take three only is the label checked for directions and the correct tablets at bedtime.” She placed the prescription bottle drug, but another check is added. The pharmacist looks at the label and asks, “Does this make sense?” on the nightstand next to the bed. Usually the answer is “Yes.” With Rita’s pre"If we cannot scription, however, three hundred milligrams That night, Rita took three tablets as preof amitriptyline at bedtime should either not count on our best scribed at bedtime. The next morning Rita’s pass the test or at least prompt one more people to be husband could not wake her up. After trying check if not a call to the prescriber’s office. perfect, what can for what seemed a long time, he called 911. During our investigation of Rita’s claim, we do to make Rita finally woke up in the ambulance on her we also discovered this is a common error. A sure this mistake way to the hospital. Rita’s prescription had computer-entry mistake, according to a small does not happen been filled with amitriptyline 100 mg tablets. survey we did when I was at Pharmacists We discovered the mistake was made by a Mutual Insurance Company, accounted for again?" technician when she entered the information over 65 percent of all medication mistakes. into the computer. She had selected the wrong We were surprised to find that more mistakes drug from the list on the computer screen were made during computer entry than durwhen she typed in “amitriptyline.” We also ing the filling process. Most of these mistakes found that this technician made fewer mistakes than anyone, were caught before they reached the patient, but not all, as including any of the pharmacists. As with all human beings, further evidenced by Rita’s case. of course, she was not perfect. Computer-entry errors include wrong drug entered; wrong We asked the pharmacy to put a new risk-management strength entered; wrong directions typed in, and even wrong technique into its procedures for filling new prescriptions. We patient’s name placed on the label and receipt. Most of these called this technique “Take 5.” In order to remind all technimistakes, often in excess of 90 percent, are caught before they cians and pharmacists to use this technique every time, we reach a patient. Some, however, are not. According to the latprepared a sign to be taped on the counter to the right of the est Pharmacists Mutual study mechanical errors account for computer entry station in the area where each prescription was over eighty percent of all claims against pharmacists. Risk manfilled. The sign read simply, in very large type, “TAKE 5.” Each agement techniques such as Take 5 can reduce the number of staff member was taught what Take 5 meant. claims and errors. Technicians and pharmacists, when filling a new prescription, are trained to take a small amount of time — up to five KEN BAKER is a pharmacist and an attorney. Baker practices seconds, to review the label before beginning to fill the prelaw as an attorney, of counsel, with the Arizona law firm scription. With each new prescription, they are to compare of Renaud Cook Drury Mesaros, Pa. He also consults in the the directions, drug name, and drug strength typed on the areas of pharmacy error reduction and risk management. label with the information on the new prescription. The first For questions or citation and footnotes, contact Ken Baker at step in filling a prescription is to double check and make sure ken@kenbakerconsulting.com. Medication Errors – Take 5 W W W.D R U GTO P I C S .C O M D E C . 8, 2008 DRUG TOPICS 3 http://WWW.DRUGTOPICS.COM
Table of Contents Feed for the Digital Edition of Drug Topics - December 8, 2008 Drug Topics - December 8, 2008 Medication Errors - Take 5 Indiana Pharmacists Identify MTMBarriers Drug Topics - December 8, 2008 Drug Topics - December 8, 2008 - Drug Topics - December 8, 2008 (Page 1) Drug Topics - December 8, 2008 - Drug Topics - December 8, 2008 (Page 2) Drug Topics - December 8, 2008 - Medication Errors - Take 5 (Page 3) Drug Topics - December 8, 2008 - Indiana Pharmacists Identify MTMBarriers (Page 4)
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.