Tips to Spot Medication Errors Outside the Hospital Pharmacy


Identifying medication use risks outside the hospital pharmacy requires something simple: speaking with other members of the health care team.

Identifying medication use risks outside the hospital pharmacy requires something simple: speaking with other members of the health care team.

At the 2015 American Society of Health-System Pharmacists (ASHP) Midyear meeting, Natasha Nicol, PharmD, FASHP, director of global patient safety affairs for Cardinal Health, and Matthew C. Grissinger, RPh, FISMP, FASCP, director of Error Reporting Programs for the Institute for Safe Medication Practices, offered some tips for pharmacists to reduce the risk of medication errors.

To start, Dr. Grissinger encouraged pharmacists to think beyond drug dispensing.

He noted that many health-system pharmacists do not look outside their hospital pharmacy to examine the medication process, such as how orders are communicated, how drugs are stored, how medications are administered, and how patients are monitored on their medications.

“I think the biggest role for the pharmacist is to get outside the pharmacy. It sounds very common sense, but there’s no one in charge of the medication use process outside of the pharmacy,” Dr. Grissinger told Pharmacy Times. “…Their role really needs to expand to…actually looking at and identifying those risks as much as they can.”

Dr. Nicol stressed communication with other members of the health care team in order to learn more about how they handle a patient’s medications. She suggested framing the conversation as a learning experience for the pharmacist, instead of a conversation about what someone is doing wrong.

“More than anything, we need to focus on prevention strategies,” Dr. Nicol told Pharmacy Times. “Pharmacists can play an integral role in this, with the multidisciplinary team, in talking to all allied health professionals and finding out why people do what they do and what their motivations are.”

Some considerations that can impact pharmacists’ job performance include external factors such as noise, the environment, and lack of training. Internal factors such as fatigue, stress, distraction, hunger, and motivation can also play into pharmacist reliability, Dr. Nicol noted.

She promoted a team approach to handling mistakes, especially because errors rarely happen due to one person, one cause, or one department.

Some of the issues that the health care team needs to tackle are being reactive to events instead of proactive, only looking at the worst events, and overreacting to single events.

Dr. Grissinger cited workflow issues, distractions during medication administration, and overwork as factors that can also lead to mistakes.

The systems of medication use that need monitoring include patient information, drug information, communication, labeling, patient education, environmental factors, staff competency and culture, and drug storage.

Dr. Grissinger also discussed common mistakes related to patient allergies and how they are communicated, as well as missteps related to measurements of weight (eg, mixing up lbs and kg).

Pharmacists should be on the lookout for unlabeled medications, syringes, and solutions, in addition to mislabeled medications and pre-labeled syringes. In addition, they should try to prevent human error with look-alike drug labels or packages.

“In my opinion, drugs don’t look alike unless they’re next to each other,” Dr. Grissinger said.

The presenters also cited an American Nurses Association survey that found 44% of nurses say they inject medicine via a syringe more than 5 times per shift.

“Are you involved in the labeling process?” Dr. Grissinger asked ASHP Midyear attendees. “Who is providing the labels?”

Only 37% of the nurses said they always label what the medication is, and 28% said they never label it. Unlabeled syringes are found in every patient care area, despite the fact that standards require syringes to be labeled.

Drug storage is also critical to keeping order, since poor control of stock can lead to mix-ups. Crowded, disorganized refrigerators and cluttered work spaces should be avoided.

“We need to be more proactive in our risk assessment,” Dr. Nicol said. “Look and find out what’s going on in your hospital.”

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