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Improving the safety of medication use


Laurence A Goldberg
Consultant Pharmacist
E:[email protected]

Improving the safety and effectiveness of medication use for all patients is the aim of Health-System Pharmacy 2015, an initiative launched by ASHP in September 2003. “Progress in achieving Health-System Pharmacy 2015 goals and objectives will speak powerfully about our profession’s commitment to high-quality patient care and our collective, national resolve to improve medication use throughout health systems,” said ASHP President Daniel M Ashby.

The Health-System Pharmacy 2015
The Health-System Pharmacy 2015 project began with a vision statement that conceptualised how pharmacy practice in hospitals and other areas of healthcare should look in the future. Six overarching goals to be achieved by the year 2015 were defined:

  • Increase the extent to which pharmacists help individual hospital inpatients achieve the best use of medications.
  • Increase the extent to which health-system pharmacists help individual nonhospitalised patients achieve the best use of medications.
  • Increase the extent to which health-system pharmacists actively apply evidence-based methods to the improvement of medication therapy.
  • Increase the extent to which pharmacy departments in health systems have a significant role in improving the safety of medication use.
  • Increase the extent to which health systems apply technology effectively to improve the safety of medication use.
  • Increase the extent to which pharmacy departments in health systems engage in public health initiatives on behalf of their communities.

Within each goal, specific objectives (including target percentages) have been set out. For example:

  • Seventy-five percent of hospitals will use machine-readable coding to verify all medications before administration to a patient.
  • Half of all recently hospitalised patients (or their caregivers) will recall speaking with a pharmacist while in the hospital.

The targets were chosen based on member input and are thought to reflect substantial, realistically achievable improvements to reach by the year 2015. ASHP has undertaken to support this initiative by conducting detailed surveys to assess progress, providing feedback to members about achievements on goals and objectives and by publicising the initiative to other stakeholders. In addition, the ASHP Best Practices Self-Assessment Tool has been developed to provide pharmacy managers with an easy-to-use instrument to identify possible gaps in relation to best practices. To use the tool, participants complete an online survey that covers nine core function categories. They then receive the results pointing to key areas targeted for improvement, in addition to an individualised list of resources available to help resolve specific problem areas. Additionally, the institution will receive a numerical score reflecting their compliance with these best practices, which can be used to benchmark itself against national statistics or track incremental improvements over time. “We are encouraging all pharmacists to work within their spheres of influence to make Health-System Pharmacy 2015 a reality,” said Henri R Manasse Jr, ASHP Executive Vice President and CEO. “For example, they can make the project’s goals and objectives high priorities within their own pharmacy departments. Together, we can significantly improve the safety and effectiveness of medication use among our patients.”

Medicare changes
New legislation – the Medicare Prescription Drug Improvement and Modernization Act –  means that pharmacists in the USA will now be paid to manage elderly patients’ drug therapies. In addition, prescription medicines coverage has been added to the Medicare programme. The two measures are seen as significant improvements for elderly Americans. “For the first time, pharmacists – who are medication-use experts – will be paid to manage patient drug therapies. This is an incredibly important step in ensuring that seniors who take multiple medications do so safely,” said Daniel Ashby.

Patients who are eligible for medication management therapy services under the Medicare reform bill include individuals with multiple chronic conditions (such as asthma, diabetes, hypertension, hyperlipidaemia and congestive heart failure), who take multiple covered medications and are identified as likely to incur annual costs for covered part D drugs that exceed a level specified by the Secretary of Health and Human Services.

“The most expensive medicine is the one that is not working for you,” said Dr Manasse. “A pharmacist is a vital partner in making sure patients get the most appropriate medicine in the most appropriate dose to avoid serious health risks.”

MEDMARX report 2002
Elderly patients are particularly vulnerable to medication errors, according to the 4th annual report of United States Pharmacopoeia’s (USP) MEDMARX   medication error reporting programme (see MEDMARX box below).(1) More than one-third of hospital medication errors that reach the patients involve those aged 65 or older, and 55% of fatal hospital medication errors reported involved elderly patients.

In 2002, MEDMARX received 192,477 medication error reports from 482 healthcare institutions, representing increases of 82.2% and 31%, respectively. The number of deaths associated with medication errors rose from three in 2001 to 14 in 2002. Errors are categorised by the stage of the medication use process at which they occur (ie, prescribing, documentation/transcribing, dispensing, administering or monitoring). Thirty-three percent of errors were reported at the administration stage, 1% during monitoring, and the remainder were more or less evenly distributed over the other three categories. Errors at the prescribing stage had increased by 40% compared with 2001. Diane Cousins, Vice- President of the Centre for the Advancement of Patient Safety (CAPS), commented that improved reporting was the most likely cause for this change, rather than deteriorated prescribing.

The report also showed that eight of the top 10 products most often involved in medication errors were high-alert medications. These eight medications accounted for 31.1% of all medication errors that resulted in patient harm. This was a similar pattern to the results from the 2001 report. The USP calls for all high-alert medications to be packaged, stored, distributed, prescribed, dispensed and administered safely to minimise the risk of harm to patients. The report concluded that, in spite of this elevated classification, healthcare facilities found it difficult to devise safe methods for handling high-alert medications.

In summarising the data, the authors of the report made a number of observations and recommendations. They noted that new technology has the potential to reduce many types of error but can also create new ones. They recommended that healthcare facilities should develop interdisciplinary teams to ensure that the implementation of such technology will not adversely affect patient safety.

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Abbreviations, acronyms or symbols were frequently associated with medication errors, and a list of those most commonly associated with errors has been produced to help healthcare organisations to design error-prevention programmes. The intravenous (IV) route of administration for medications often resulted in the most serious outcomes. The report recommended that institutions should be encouraged to adopt standardised procedures for the use of IV medications, and also endorsed the use of programmable infusion devices that can be customised to meet the hospital guidelines. Lastly, the report noted that “wrong administration technique” and “wrong route” accounted for a disproportionate number of harmful errors, and should be targeted in education, product packaging and storage. In particular, hospitals should examine the policies and procedures for the correct administration of medicines and should establish systems to prevent accidental IV, intrathecal or epidural administration of medications.

Human error
Medication errors can be predicted by focusing on the individual. Human engineering is not only possible but is also necessary, according to Dr Robert Pihl (Professor of Psychology, McGill University, Montreal, Canada). Systems myopia leads us to believe that barcoding and automation, for example, will solve many of the problems, but the pendulum has swung too far towards system failure and needs to swing back towards human failure, he said.

A battery of tests, including measurements of working memory and personality tests, can be performed on individuals to identify those prone to making errors. Dr Pihl went on to describe a small study comparing a group of pharmacists who had made dispensing errors with a control group.

The pharmacists from the dispensing error group were older, more experienced and had reduced working memories. They also had associated learning deficiencies that made it more difficult for them to distinguish between lookalike/soundalike names. Their test results fell in the lower quartile on all neuropsychological factors. However, the personality tests showed no differences between the groups. Professor Pihl concluded that the characteristics of individual pharmacists were important in reducing medication errors.

Anticounterfeiting measures
Health-system pharmacists now have a resource to aid their ongoing efforts to ensure the integrity of medicinal products. The American Society of Health-System Pharmacists has developed strategies that practitioners should follow to help prevent the acquisition of counterfeit drugs.

The recommendations encourage pharmacy departments to educate pharmacy staff and other health professionals on the problem of counterfeiting and how to screen product packaging. Practitioners are advised to be in regular contact with primary wholesalers and state boards of pharmacy to limit the use of secondary distributors and establish system-wide procedures for reporting suspicious products. The guide also includes a list of suggested security measures (see Table 1) to minimise the risk of diversion or entry of counterfeit products into the pharmacy and a list of medications at high risk for counterfeiting.


It is also recommended that all pharmacy staff should be educated on the problem of counterfeiting, what they should look for and how to report a suspicious product.  Another recommendation was that comments and complaints about medicines should be taken seriously and should be investigated promptly. Many counterfeit products were discovered only after patients complained of a change in effectiveness or a change in taste of their oral medications.

The recommendations, developed by ASHP’s Section of Pharmacy Practice Managers, are part of ASHP’s efforts to keep its members up-to-date with problems in the pharmaceutical supply chain (see Resources). The recommendation will be updated regularly. ASHP also provides rapid alerts to members and hospital pharmacy departments about counterfeit drug incidents, and it maintains an online Drug Shortage Management Resource Center that provides updates on current drug product shortages and recommends therapeutic alternatives.


  1. Hicks RW, Cousins DD, Williams RL. Summary of Information Submitted to MEDMARX in the Year 2002. The Quest for Quality. Rockville (MD): USP Centre for the Advancement of Patient Safety; 2003.

ASHP Best Practices Self-Assessment Tool
ASHP Strategies to Protect Against Counterfeiting

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