Articles Posted in Patient Safety

Pharmacy errors can occur at different stages of the process of prescribing and dispensing a medication. And although some pharmacy errors may be caught quickly or may have a short-time effect, others can be devastating for Maryland pharmacy error victims. To decrease the prevalence of pharmacy errors, many researchers have looked to documented cases to determine where and how changes can be made.

According to a recent article, the labeling and packaging of medication contributed to two recent pharmacy errors. In one case, the prescriber of a mediation had prescribed sacubitril-valsartan (Entresto), a multi-ingredient medication that combined two drugs. The prescriber listed the strength of the medication prescribed as 100 mg, which was to be taken twice a day. When the pharmacist was filling the prescription, the pharmacist saw that the medication did not include a 100-mg strength, so the pharmacist chose the closest choice—97/103 mg strength (97 mg of one drug and 103 mg of another). However, the prescriber had intended that the patient take the total amount of the 2 drug ingredients (49/51) with 100 mg total.

The patient’s doctor later increased the dose to 100 mg, which was to be taken twice a day. The pharmacist dispensed the same 97/103 mg medication and gave instructions to take two tablets twice a day. The patient had severe adverse effects and the error was discovered. The insert on the medication suggested that the total amount was the basis for clinical trials, but the label listed the ingredients separately. To make matters more confusing, other combination tablets are prescribed according to the strength of each drug rather than the total, such as carbidopa-levodopa (for example 25-100).

Most Maryland residents find themselves visiting a pharmacy at one point or another. Medications—whether continual or short-term—are a big part of many people’s health and well-being. And ideally, pharmacists and pharmacies help to keep Maryland patients safe and healthy. But sometimes mistakes are made, and these pharmacy errors can cause significant harm to patients. In fact, Maryland pharmacy errors are more common than most people think and can happen to anyone. Recently, however, the Pharmacy Times published an online article about how specialty pharmacists play an important role in increasing patient safety.

Specialty pharmacies, according to the Academy of Managed Care Pharmacy, are distinct from traditional pharmacies and are designed to efficiently deliver medications that have special handling, storage, and distribution requirements. They are also designed to improve outcomes for patients that have complex, potentially chronic and rare conditions. Typically, patients taking specialty medications require more complex services than those required for a traditional drug, and so specialty pharmacists step in to meet those needs.

According to the Pharmacy Times, specialty pharmacists have a unique role in medication safety. Not only do they take responsibility for ensuring the safe and effective use of specialty medications, but they also play a strong role in promoting a positive safety culture within their specific pharmacy. One of the factors pointed towards as causing pharmacy errors is the culture within the pharmacy. Oftentimes, pharmacists are overworked, hurried, and stressed out, and they may sacrifice safety for speed or fail to engage in regular safety precautions. The Pharmacy Times reports that because specialty pharmacists, working with high-risk specialty medications, often incorporate robust programs to ensure proper medication usage and minimize the potential for error, can be really helpful in setting the tone and expectation for safety in typical pharmacy settings. Additionally, specialty pharmacists can encourage the actual reporting of errors within pharmacies when they do happen, which is critical for addressing the root cause of the problem and making sure the same errors do not continue to happen.

Each year, medicine and technology get more and more advanced, leading to improvements in the quality and delivery of health care across the country. Despite these improvements, however, errors still occur in health care delivery, particularly regarding pharmacy and medication. In fact, Maryland pharmacy errors occur frequently, jeopardizing the health and well-being of patients. The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with health care practitioners, institutions, regulatory agencies, professional organizations, and the pharmaceutical industry to create awareness of and provide education about medication errors and how to prevent them.

Every other week, ISMP produces a newsletter with timely information related to pharmacy error prevention. Looking at the newsletters from January 2020 through December 2020 provides important insight into the trends seen in pharmacy errors last year. Pharmacy Practice News recently provided a summary of these newsletters on their website.

In the Pharmacy Practice News summary, several key problem areas were identified. One was safety issues related to labeling, packaging, and nomenclature. For example, a pharmacist might mix-up two different medications that have similar labeling or names, giving the wrong one to the patient. Another area of concern was safety issues associated with order communication and documentation. For example, health officials searching for drugs by generic names and accidentally substituting non-substitutable drugs. Finally, there are problems involving drug information, patient information, patient education, and staff education. For example, two patients mixed up their insulin pens which looked alike but with different labels and manufacturers, meaning they gave themselves the wrong insulin, leading to hyperglycemia.