By Michael Ross and Diem Pham, Founding Partners, ROAMcare
“To Err Is Human” has long been a struggle and is a focus of the culture of safety in hospitals and health care settings. Since the Institute of Medicine published this powerful report in 1999, great strides in medication safety have been made by pharmacy departments and services that have taken responsibility for drug safety and safety related education as professional mandates. That earth shattering report estimated between 44,000 and 98,000 deaths per year were attributable to medical errors, and 7,000 of those were drug related. It further went on to estimate that up to 2% of hospital admissions were exposed to a medication error and that fully half of adverse medication related errors and adverse events were preventable.
Since the beginning of this century pharmacy leaders have encouraged non-punitive reporting systems to first identify errors and opportunities for errors, then strengthened education opportunities moving beyond error recognition to error prevention. Education activities centering around look alike/sound alike drug names, dangerous abbreviations, and filling and distribution tasks moved out of the pharmacy and physician offices and into pharmacy care areas where drug storage, administration, reconciliation, and adverse event reporting were studied and improved. Medication handling was restricted to within the pharmacy in most hospitals, limiting nursing units or bedside preparation of medication to emergency uses only. The use of centrally prepared and distributed oral and parenteral medications, particularly IV additive medications, increased. The efforts were not in vain. The World Health Organization noted in a 2016 report that pharmacy led intervention programs were reducing reported medication errors and encouraged the continuation of pharmacy directed medication safety activities or their implementation where they were not already a standard practice.
Then the novel corona virus SARS-CoV-2 burst on the scene resulting in COVID-19 and the spate of pandemic related restrictions. Included among these were the reduction of staffing in hospitals to essential personnel and limiting access to care units, including the important intensive care units to all but direct hands-on patient care workers. Pharmacy again was shoved to the basement.
COVID-19 challenged the medication delivery system in hospitals and health care facilities. How you and your pharmacy respond to the challenges can directly affect your medication utilization and exposure to potential errors that may lead to significant adverse events. In areas where pharmacy access to care areas has been restricted and nursing staff is limited, preparation of immediate use doses and out of pharmacy IV preparation is inevitable. When this occurs, ensure that specific, clear instructions for preparation and labeling are in place to mitigate potential preparation errors. Identifying drugs that can be safely administered without smart pump technology can help enhance availability of equipment throughout the facility. As restrictions begin to ease, it is essential that pharmacy regain control of medication practices, not only ensuring a more controlled environment for medication preparation but also releasing nurses for more bedside care.
Given the many changes and re-prioritization of workload and workflow, reports of safety related issues including dispensing and administration errors may have been suspended, sporadic, or not considered at all. It may be easy to put off and forget when there are competing priorities. Make time to delve as deep as possible to review the reports. Your overview will put you in a better position to address and correct inaccurate information where and when necessary.
The world may be in turmoil due to the tiny invisible SARS virus. Medication safety shouldn't be.