Pennsylvania hospitals experienced more than 500 breakdowns in the medication reconciliation process between November 2011 and November 2012, according to the December issue of the Pennsylvania Patient Safety Advisory.
"While most patients were not harmed, these events should be looked at to make necessary improvements to the medication reconciliation process to avoid harm," Mike Gaunt, PharmD, patient safety analyst for the Pennsylvania Patient Safety Authority, said in a statement.
The Authority identified 501 breakdowns, 69 percent of which occurred during admission medication reconciliation, according to the article. The events occurred most commonly during the prescription (40 percent) or transcription process (27 percent).
Of the events recorded, 337 reached the patient whose medication was involved, and 87 both reached the patient and required clinicians to ensure that the patient was not harmed or in need of intervention to prevent harm, according to the report.
"Drug omissions, for example, missing a drug or dose, was the most frequently reported event type overall, with one hundred and thirty-four reports," Gaunt said. "Other top event types reported included patients receiving the wrong dose or additional drug or dose."
Gaunt suggested several strategies to reduce the breakdown risk in the future. These include:
Standardizing the process by which staff obtain medication histories;
Clearly defining staff roles and responsibilities;
Providing regular assessments of the reconciliation process;
Promoting involvement by both patients and caregivers; and
Factoring in the design of electronic health records.
"While some of these tasks to reduce the risk can take some time, it's worth the effort to minimize the risk of a medication error reaching a patient," Gaunt said. "The importance of the patient or caregiver's role in giving an accurate medication history cannot be stressed enough."
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