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According to the US Department of Health and Human Services, adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Hospital pharmacists are uniquely positioned to prevent medication errors in the hospital because of their centralizing function for medications prescribed and dispensed within the hospital setting.

It was with the goal of understanding the role hospital pharmacists can play in preventing medication errors that I interviewed Steven Meisel, PharmD, who is a patient safety expert at the Institute for Health Care Improvement (IHI) and the Director of Medication Safety at Fairview Health Services in Minneapolis.

In this clinical education podcast, Dr. Meisel discussed how hospital pharmacists can prevent medication errors. (His transcribed quotes have been lightly edited for readability.)

Here are his five recommendations for accomplishing this:

 

  • First, recognize that you may have medication errors

Dr. Meisel’s hospital recognized they had a problem with medication errors related to patients receiving opioids. As he explained:

“I think the first piece of advice is to recognize that there is a problem. Just like the alcoholic can’t change his ways and get better before he admits he is an alcoholic, the hospital can’t reduce its risk for narcotic oversedation until it believes that there is a risk for narcotics oversedation.”

Meisel’s hospital realized that they had an issue related to opioid administration because they recognized the implications of naloxone usage. He explained,

“It’s very interesting, we started our journey on this about 15 years or so ago. One of the things that we learned in talking to physicians, anesthesiologists, surgeons, even our vice president for medical affairs at the time was the same story that you just mentioned, that we didn’t have a problem here with narcotics oversedation. Then we looked at the naloxone administration and said, ‘well, gee, we’re using an awful lot of this.’ And the response was ‘Well, of course, we are because that’s what naloxone on is on the market for. People aren’t suffering because we have this antidote.’

 And so it is important to change the mindset that the use of naloxone is not a cost of doing business. That it’s not a choice of good pain control versus somebody being over sedated or stopping breathing. You can have both, you can have good respiratory function and good pain control, but the use of naloxone is not a cost of doing business. And I think when people say they don’t have a problem, it may be because people are not dying or not becoming comatose with long-term central nervous system problems or whatever, but gosh if they stop breathing and they’ve got to be given naloxone, that is something you’d not want for yourself or your spouse or your parents and therefore it is not the cost of doing business.”

 

 Because of their recognition of the problem, Dr. Meisel’s hospital was able to lower their medication errors by 82%:

“We have not, thankfully, had any patient deaths, at least not in a recent time. But I can tell you that, yes, we have seen an impact on narcotic-related adverse events. In fact, at our university hospital alone, from 2008 through 2016, we had an 82% reduction in our narcotic-related adverse events. 



 

  • Second, use standardized order sets.

Standardized order sets help eliminate errors making sure they are not caused by human error:

“We have to make sure that we implement every known best practice that is out there, and there are lots of them, as you know. From the Institute for Safe Medication Practices or from the IHI or from other professional organizations. There are lots and lots and lots of best practices and, unfortunately, way too many of them are just not deployed to the extent that they should be. I think it’s very important that we deploy all those best practices and we deploy them in ways that can assure that they’re actually operationalized throughout the organization. You build them into order sets in your electronic health records, you build them into your pharmacy computer system, you build in forcing functions such as IV tubing that can’t be connected inappropriately to an intravenous line or vice versa, you have pumps that are different for epidural versus IV and those sorts of things.” 



One of the forcing functions that Dr. Meisel’s hospital built into their order sets was the need to continuously electronically monitor all patients for the first 24 hours following surgery:

“In the acute post-op setting, we require that any adult inpatient who has an order for narcotics undergoes a continuous capnography monitoring for the first 24 hours after the surgery and then longer depending upon if the patient is doing well or poorly or whatever, and then we also apply continuous pulse oximetry in that setting as well. So, they have both continuous pulse oximetry and capnography for the first 24 hours after surgery for all of our adult inpatient patients. 



 

  • Third, think innovatively to develop best practices

When faced with an obstacle that may cause a medication error, think innovatively to develop best practices. Dr. Meisel described this example of how they innovated to prevent oversedation events:

 “I think you’ve got to innovate, you’ve got to invent new best practices. What we have learned is that you could deploy everything that’s out there, but you will still suffer adverse events and your patients will suffer adverse events. So you’ve got to dream up new ways of doing business, new approaches to the care of the patients that you’re seeing whatever the condition may be and identify new ways of doing business.

 So for example, in the narcotic world, you want to prevent oversedation events and one of the risk factors might be that hydromorphone comes in 1-milligram and 2-milligram prefilled syringes, but the normal dose is about 0.2  or 0.4 milligrams. So, why would you buy 2-milligram syringes for use in most parts of your hospital? That’s a risk and so one of the solutions that Fairview deployed for a decade was to repackage every hydromorphone syringe into 0.4-milligram sizes and we did that for a decade until a 0.5-milligram size became commercially available. That was innovation, it was inventing a new best practice to try to eliminate the risk of that 10-fold overdose that, albeit rare, was always there.

 

  • Fourth, measure to see how well you’re doing

Dr. Meisel recommends keeping track of how you are doing:

“You can’t improve what you can’t measure, at least not very well. For the last ten years or more, we have run charts every quarter showing the number of narcotic-related adverse drug events plotted over time, by hospital, and as an aggregate. We post the results regularly to be reviewed by our pain committee, our pharmacy and therapeutics committee, and others. Because we have that measure, we know whether we’re getting better, staying the same, or in some cases, at times, getting worse, if that’s the case. You’ve got to measure, I think that’s very important. 



 

  • Fifth, be committed to patient safety

Make sure that your hospital is committed to patient safety, and this starts from strong leadership:

“I think it, first of all, starts with strong leadership and strong culture. From the top of the organization right through the all the rungs of the organization.

There has to be a belief that safety is important value, that it is as important as quality and finance and all the rest.

There’s got to be good training, good recognition, good rewards and good expectation setting. It needs to be a part of the report and discussions at every level from the board all the way on down, that’s very important.”

To learn more about these and other recommendations for preventing medication errors in the hospital, please listen to the clinical education podcast with Dr. Meisel, by clicking here.

Michael Wong, JD
Michael Wong, JD is the founder and Executive Director of the Physician-Patient Alliance for Health and Safety (PPAHS). He has been at the forefront in driving practical solutions that reduce healthcare costs, decrease medical errors, and improve patient health outcomes. He has been particularly active in these areas that most affect patient safety: • Improving patient adherence (i.e. helping patients to take their medications as prescribed by their physicians) • Enhancing patient access to healthcare • Reducing medical errors (PPAHS), is an advocacy group of physicians, patient advocates, and healthcare organizations. Supporters of and commenters for PPAHS include highly respected physicians and healthcare organizations, including the The Joint Commission, Anesthesia Patient Safety Foundation, Anesthesia Quality Institute, Johns Hopkins School of Medicine, Harvard Medical School, Stanford University School of Medicine, and the Cleveland Clinic.

6 COMMENTS

  1. I think number 4 is the most important advice in this post

    And that´s because measuring provides a specific data of each event, we can study what´s happening in every case if we know how to read the numbers

    Be well

    • Thank you for your thoughts, Dr. Marcano. Agreed, measurement is critical, but the information received must be acted upon. As Mr. Meisel points out in the podcast, often clinicians and hospital executives believe incorrectly that no problem exists. Awareness begins with understanding that there is problem.

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