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Philip J Schneider
Clinical Professor and Director Latiolais Leadership Program
College of Pharmacy Ohio State University USA
Between 44,000 and 98,000 people die every year as a result of the care that they receive in US hospitals, with as many as 7,000 of these due to medication errors.(1) These sobering statistics have resulted in patient safety taking centre stage as a public policy issue. Improving medication safety has been an important part of the professional attention of pharmacists for several decades, even though it has only recently gained public interest. Research by pharmacists 40 years ago documented the incidence of drug administration errors in hospitals as being 10% or higher. This provided the impetus to develop drug distribution systems that were safer, including unit-dose drug distribution systems and intravenous admixture programmes. These systems were demonstrated to be at least twice as safe as the floor stock system that they replaced.(2) Systems where the responsibility for preparing, distributing and administering medications was given to pharmacy personnel were a further advance in improved medication safety, and they reduced medication error rates to less than 1%,(3) the lowest medication error rate ever documented.
So why, after several decades of systems improvements by hospital pharmacists, is medication safety only now at centre stage with the public? Have hospital pharmacists maintained their focus on developing and maintaining safe medication systems? Several changes highlighted the need to refocus attention on safe medication use in hospitals. Changes in reimbursement for healthcare from a fee-for-service to other methods have resulted in patients receiving care at home or in extended-care facilities. Those patients who remain in the hospital are sicker and are there for shorter periods of time. The number of different medications and doses that they receive is now much higher. Many drugs are administered parenterally, orders change frequently, and doses are needed quickly. Traditional pharmacy-based unit-dose and IV-admixture programmes are now perceived as being unable to respond to the pace and dynamics of care in hospitals with patients who are critically ill. Newer point-of-care systems, including drug dispensing cabinets located in the patient care area, are replacing centralised unit-dose drug distribution systems so that nurses can obtain doses more rapidly. If not linked to the pharmacy system, these cabinets are no safer than the floor stock systems that were shown to be unsafe 40 years ago. In addition to point-of-care drug dispensing cabinets that are linked to the pharmacy information system, other technologies are being used to improve medication use safety. Barcode bedside documentation systems have been developed that enable nurses to check each dose at the bedside to verify patient and dose identity, and the appropriateness of the time at which the dose is being administered. Computer order entry systems with decision support logic are providing prescribers with information about the medications they are prescribing and the patients they are treating so that fewer errors occur.(4)
So, what is left for the hospital pharmacist to do? As many as 39% of adverse drug events are the result of errors made in the prescribing step of the medication use process.(5) Two-thirds of these errors can be detected and resolved by having a pharmacist in the patient care area when medications are prescribed.(6) Thus, hospital pharmacy in the USA is continuing to become a more patient-oriented practice. Drug costs in the USA continue to rise faster than the rate of inflation, while preventable adverse drug events are estimated to result in unnecessary costs of more than $5,000 per case, and $1.5m per year in a large hospital.(7) Pharmacists are increasingly being asked to help manage these costs.
While hospital pharmacy was considered to have had a “golden era” during the fee-for-service days when unit- dose and IV-admixture programmes were developed, the current public concern about safety is providing an opportunity for another such period.