HARRISBURG: More than 3,800 preventable adverse drug events are caused from healthcare providers not having sufficient information about the patient’s documented allergies before prescribing, dispensing and administering medications, according to analysis provided in the Patient Safety Authority’s 2008 September Patient Safety Advisory.
Review of the data submitted to the Authority shows that in 3,813 cases patients received medications to which they had documented allergies and 61 of those patients (1.7%) suffered harm as a result of the error. Narcotics and antibiotics were the most common medications listed in reports and those which caused the most harm to patients once administered incorrectly.
Types of breakdowns in the communication of allergy information include: documentation of patients’ allergies on paper but not entered into the organization’s computerized order-entry systems; allergy information not consistently documented in expected locations; organizations’ attempts to list every drug allergy on a patient’s wristband; and allergies arising during episodes of care but not documented in the medical record or communicated to appropriate staff.
“As with many medical errors there are several factors that come together that increase the chances of a medical mistake occurring whether it be a medication error or another type of mistake,” Michael Cohen, RPh, MS, ScD, advisor to the Pennsylvania Patient Safety Authority and president of the Institute for Safe Medication Practices said. “The data in these cases clearly shows that many process changes can be made that involve communication among healthcare providers and the patient to significantly decrease the risk of a medication error occurring.”
Within the data analysis of the errors, the Authority noted breakdowns in patient information, including allergies, diagnosis, pre-existing conditions, and current medication lists and labs that involve breakdowns at each level of the medications-use process.
“Many of the errors that occurred were due to breakdowns in communication either when providers were obtaining information from the patient or caregiver or from other healthcare providers,” Cohen said. “Others happened when providers documented incorrect information into electronic medical records or entered orders incorrectly into other medication computer systems.
“If the healthcare provider prescribing the medication to the patient does not receive accurate information at the time of dispensing the medication from these devices meant to prevent medication errors, then opportunities for double-checking if the correct medication has been prescribed is lost,” Cohen added.
The Authority suggests guidance for healthcare providers to implement to ensure that current and complete allergy information is accurately and clearly collected and readily available to all practitioners at the point of care when they are prescribing, dispensing and administering medications. The Authority also offers tips for consumers to ensure they are protecting themselves from an adverse medical error, particularly if they are allergic to certain medications.
For more information on medication errors and their significance with allergies go to the article “Medication Errors Associated with Documented Allergies” of the 2008 September Pennsylvania Patient Safety Advisory at www.patientsafetyauthority.org.
The Authority’s quarterly 2008 September Advisory contains other articles developed from data submitted through real events that have occurred in Pennsylvania’s healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:
- Anticoagulation Management Service: Safer Care Maximizing Outcomes: The Authority has received hundreds of Serious Event reports associated with anticoagulation (blood thinning) therapy with poor outcomes. The complexity of administering blood thinners has resulted in patients’ safety being compromised and has even caused death for some patients. Additional educational tools are provided that include: a video about the benefits of an anticoagulation management service program, a link to a sample failure mode and effects analysis about anticoagulants and self assessment tool provided by the Institute for Safe Medication Practices (ISMP) and a link to a toolkit provided by the Institute for Healthcare Improvement (IHI) for safe and effective anticoagulation therapy in all healthcare settings. In related news, the Joint Commission recently released a Sentinel Event Alert about sentinel events involving anticoagulants. An educational toolkit is available for healthcare providers by clicking here.
- Caring for Pregnant Patients in the Emergency Department: The Authority has received reports that show mismanagement of pregnant patients in the emergency department. When a pregnant patient arrives at the emergency department, there are really two patients. Often the reports show a lack of communication between emergency and obstetrics services that may put the patient and fetus at risk. Risk reduction strategies are included.
- Malignant Hyperthermia (MH): A Rare Condition that Can be Deadly if not Treated Properly: MH is an inherited disorder of the skeletal muscle, triggered in patients by general anesthetics. The occurrence, while rare, may suddenly develop with rapid progression of symptoms resulting in death. The Authority has received 15 reports of MH with one death. Prompt identification and treatment are essential for a favorable outcome. The focus of prevention is to ensure the drug used to treat MH is readily accessible and administered quickly enough for recovery of the patient.
- Hand Hygiene Practices and the Use of Alcohol-Based Sanitizers: The article stresses the importance of hand hygiene and the additional benefit of using alcohol-based sanitizers. Recently, the Authority supported the Centers for Disease Control and Prevention (CDC) in calling for “Clean Hands Week” to promote better hand hygiene. The article lists system failures and barriers to effective hand hygiene and components of successful hand hygiene programs.
- Wrong-Site Surgery Quarterly Update: The Authority also gives a quarterly update on its wrong-site surgery project. The update shows system breakdowns continue that lead to wrong-site surgery events. Of particular interest, 38 percent of the new reports are of wrong-site injections. The Authority has completed its follow-up study with healthcare facilities regarding their wrong-site surgery protocols and will give a complete update on the study in its 2008 December Pennsylvania Patient Safety Advisory.
For more information on the Pennsylvania Patient Safety Authority, visit the Authority’s website at www.patientsafetyauthority.org.
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