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Published on 1 November 2007

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Improving patient safety: a challenge for German hospital pharmacy


Jochen Schnurrer


ADKA (German Society of Hospital Pharmacists) Working Group on Medication Errors

Head Pharmacist
Central Pharmacy
St Bernward Hospital



Six per cent of all hospitalised patients are affected by adverse drug events (ADEs), of which 30% are considered to be ­preventable since they are caused by medication errors (MEs).[1,2] Thus, the prevention of MEs leading to ADEs ­represents a direct contribution to patient safety and a task for the hospital’s drug experts, the ­hospital pharmacists.

The special situation German hospital pharmacists are faced with derives from the fact that ­German hospital pharmacies are among the ­poorest staffed in Europe, with each pharmacist providing service for an average of 300 beds. In leading EU countries that ratio is 1:40. The poor staffing of pharmacies reflects the fact that many hospitals do not have pharmacies of their own. For these hospitals, pharmaceutical services have to be provided over a distance. Both facts lead to a situation where personnel-intensive strategies to improve patient safety – such as having ward pharmacists – ­cannot be employed. Therefore, other strategies are required. The development of such strategies is the appointed task of the Medication Errors Working Party founded by the German Society of Hospital Pharmacists (ADKA) in 2004.

As a first step, the working party set up an online ME reporting system. This went live in ­January 2005. Since this time more than 300 medication errors have been reported by German hospital pharmacists. The analysis of these error reports and of ­published international studies forms the basis for recommendations on how MEs leading to ­preventable ADEs can be minimised. The easier the strategy can be put in practice, the better. Often it is enough simply to be aware of the fact that certain actions have a possible influence on patient safety. That this awareness might already make the difference can be demonstrated at the purchasing level.

Improving safety at purchasing level
Deciding which drugs are listed in the hospital’s drug formulary is a principal task of hospital pharmacists. By including patient-safety aspects within these decisions, hospital pharmacists can reduce the risk of MEs on the wards.

The analysis of distribution errors detected in the hospital pharmacy is an effective way to identify error-prone drugs. It is assumed that distribution errors occurring in the hospital pharmacy will also occur on the ward, with the consequence that patients are treated with the wrong drug. The risk of drugs being confused increases with the number of drugs that look or sound similar. Look- and sound-alike drugs were involved in 15% of all errors reported to ADKA’s ME reporting system. Simply selecting drugs with unique package designs and brand names can lead to an error-rate reduction even if the pharmacists are not physically present on the wards.

Another approach is to try to reduce intravenous medication errors by purchasing ready-to-use solutions and single-dose syringes, since the risk of medication errors is increased when multiple-step preparations of IV drugs are required on the ward.[3]

Error rates can also be reduced by taking the pharmacokinetics of the active agent into consideration. An agent that interacts with CYP enzymes will increase the risk of clinically relevant interactions. If there is a choice between two agents, the one with the least potential for CYP-enzyme interactions should be chosen. The same applies to drugs that can be administered using a standard dosage without need for dosage adjustments for patients with impaired renal or hepatic function.

These examples show that hospital pharmacists can make a significant difference to patient safety by purchasing safe and easy-to-use drugs.

Pharmaceutical admission services
Implementation of pharmaceutical admission ­services is another strategy to reduce error rates. By focusing on patients with elective surgery interventions, such a service can be provided even over a distance. These patients can be asked to fill out a questionnaire regarding their long-term medication and hand it to the surgeon when being interviewed, usually a week before actual admission. The ­completed questionnaires are sent to the hospital pharmacy and checked for interactions, dosing errors and double medications. Recommendations on how to adapt the patient’s long-term medication to the drugs in the formulary and information on drugs that have to be ordered specially for the patient ensure that, at the time of admission, the patient’s medication is quality-checked and on the ward’s stock.

Centralised IV services
Centralised IV services are provided by almost all hospital pharmacies for cytotoxic drugs. For such drugs prescriptions are sent to the pharmacy with patient data needed to evaluate the prescription. By delivering quality-checked ready-to-use IV medications, error rates on the ward are reduced. The same applies to IV services for total parenteral nutrition.

Unit-dose drug distribution
Taking the poor staffing of German hospital pharmacies into consideration, unit-dose drug distribution provides an interesting way for hospital pharmacists to take an active part in the patient-based medication process. The idea is that the patient virtually enters the hospital pharmacy and the pharmacist checks the medication without having to leave the pharmacy. This allows such services to be provided by German hospital pharmacies even over a distance. At present 20 German pharmacies have established such a service for their patients. Due to the fact that unit-dose drug distribution for all patients in a hospital requires a unit-dose packaging machine and CPOE software, it is not a strategy that can be implemented overnight. However, there is no need to start at the high end. One recommendation of the ADKA working party is to begin unit-dose distribution with a focus on high-risk drugs. Methotrexate is a good example – deaths due to daily instead of weekly dosage administration are well documented and can be prevented by eliminating this drug from the ward cabinet.[4] Such an approach can be employed without the need for CPOE software or a packaging machine and is highly effective.

Preventing medication errors leading to adverse drug events is a principal task for hospital pharmacists and can be best performed by ward pharmacists operating as part of the therapeutic team. Due to poor staffing of hospital pharmacies, such an approach is not possible in Germany. Nevertheless, by implementing medication error reducing ­strategies that work from within the pharmacy hospital pharmacists can contribute to patient safety.

1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274(1):29-34.

2. Bates D, Spell N, Cullen D, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997;277(4):307-11.

3. Taxis K, Barber N. Incidence and severity of intravenous drug errors in a German hospital. Eur J Clin Pharmacol 2004;59(11):815-7.

4. Sinicina I, Mayr B, Mall G, Keil W. Deaths following methotrexate overdoses by medical staff. J Rheumatol 2002;32(10):2009-11.



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