Meetings and Conferences

World Congress of Pharmacy and Pharmaceutical Sciences

Pharmacists can help prevent and minimise medication errors

Medication errors would never be completely eliminated, simply because to “err is human,” according to Dr Sumon Sakolchai (faculty of pharmaceutical science, Khon Kaen University, Thailand). However, pharmacists, doctors and nurses could do much to prevent and minimise them.

Dr Sakolchi was speaking at a symposium on medication errors on 5 September. He said that in most countries it was the pharmacist who was responsible for dispensing medicines. Pharmacists should therefore be aware of factors leading to dispensing errors and should ensure their systems are set up to prevent or reduce errors, he emphasised.

This meant paying attention to issues such as the work environment and reducing distractions within it. An efficient system for storing stock was also essential — for example, separate storage of look-alike packages and regular inspection of the inventory for expired or out-of-date items. A well-designed computer system could improve awareness of medicines with similar names. Thorough prescription assessment and independent checking of dispensed items went without saying, and talking to patients about their medication, even though this was something that pharmacists all over the world were paying increasing attention to, should be recognised as a means not only of communicating information about medication but also as a means of reducing medication errors. One study had shown that 83 per cent of errors were discovered during patient counselling and therefore corrected before the patient left the pharmacy. This was part of the pharmacist’s responsibility for the patient’s drug therapy, highlighting the importance of good pharmaceutical care, he concluded.

Enhancing safe drug use in the Netherlands

Professor Dick Tromp, professor in pharmaceutical care, University of Groningen, the Netherlands, re-emphasised that providing proper pharmaceutical care could prevent drug therapy problems. Evidence from a recent project in a Dutch community pharmacy setting suggested that changes initiated by the pharmacist could protect patients from drug-related problems in more than 9 per cent of prescriptions presented.

The aim of the project was to look at the ability of pharmacists to enhance safe drug use by initiating changes in patients’ medication or other interventions as a result of computer-generated alerts.

All computer generated medicine alerts were collected in 18 independent community pharmacies over a four-week period in 1999, together with details of the workload in each pharmacy.

The pharmacy staff documented any interventions made as a result of the medication alerts using a so-called “care activity code”. These codes were related to pharmaceutical care activities such as identification of drug interactions, contraindications, allergies, duplicate medication, drug identity problems, strength or dose different from that prescribed previously, incorrect patient data, unusual quantity and first time dispensing.

The number of computer generated alerts per 100 prescription items fluctuated per pharmacy from 24 to 51 (average 35), while the number of care activity codes per 100 items fluctuated per pharmacy from 12 to 46 (average 24). Some 24 per cent of the prescriptions resulted in an activity that was documented, and of those documented activities, 38 per cent resulted in a direct intervention such as advice to the doctor, a change to the prescription or the provision of additional advice to the patient.

Lessons learnt from the project, Professor Tromp concluded, were that measurement of pharmaceutical care activities in pharmacies is possible, although the well known fact that pharmacists do not like to document their activities meant that there was a need to focus on ways of motivating them to do so. This was an essential requirement for generating evidence that pharmacists could make a difference in improving safety and preventing medication errors, he said.

Developing a medication error reporting system

In the opinion of Susan Proulx, of the Institute for Safe Medication Processes, US, human error was essentially system error and the focus of error reduction efforts must therefore be on improvements in medication systems. Since 1975, the US has had a national program to which pharmacists and other health professionals have reported medication errors. Operated by the United States Pharmacopoeia in co-operation with ISMP, the program was a voluntary one and similar programs have also been set up in Canada and Spain.

The ISMP was prepared to help pharmacists in other countries who wished to establish national reporting programs. To work with ISMP in this way demanded certain leadership and organisational requirements, and further details could be found on the organisation’s web site at www.ismp.org.

FIP activity

In his presentation, Thomas Thielke, chairman of the FIP working group on medication errors, US, emphasised the importance of ongoing co-operation between FIP and ISMP. He reminded participants that one of the recommendations of the FIP working group on medication errors was that ISMP should continue to share information with FIP on medication errors reported worldwide and on systems to improve the safety of medication use for distribution to FIP members. Another recommendation of the working group was that FIP should be instrumental in developing and sponsoring medication error reporting systems worldwide, which should be co-ordinated by affiliates of ISMP.