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SOURCE Pennsylvania Patient Safety Authority
Of the reported medication events 337 reached the patient but most did not result in patient harm, however three percent or 18 patients were harmed
HARRISBURG, Pa., Dec. 17, 2013 /PRNewswire-USNewswire/ -- Pennsylvania Patient Safety Authority analysts identified 501 reports involving breakdowns in the medication reconciliation process with a majority of the events occurring during admission medication reconciliation, according to an article in the December Pennsylvania Patient Safety Advisory released today.
"Medication reconciliation is the process of comparing the list of medications a patient is taking while at home with newly ordered medications in the hospital to identify and resolve any differences in the medications," Mike Gaunt, PharmD, patient safety analyst for the Pennsylvania Patient Safety Authority said. "The analysis showed that while most patients were not harmed, these events should be looked at to make necessary improvements to the medication reconciliation process to avoid harm."
The 501 reports were from event dates between November 1, 2011, and November 31, 2012. The majority of events occurred during admission medication reconciliation (69%, n=347). Events most often originated during prescribing (40%, n=202) and transcribing (27%, n=135).
"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 added that of the 501 events 337 reached the patient; 87 of the events reached the patient and required monitoring to confirm it resulted in no harm to the patient and/or required intervention to preclude harm and 18 of the events resulted in patient harm.
"Most events [40%] occurred during the prescribing phase of the medication reconciliation process," Gaunt said. "The care areas in which they occurred varied from the emergency department to pharmacy, with a majority of the patients involved in the events sixty-five or older."
Gaunt added some risk reduction strategies include standardizing the process for obtaining and communicating complete and accurate medication histories, defining roles and responsibilities for all staff, addressing the design of electronic health record systems, encouraging patient and caregiver involvement and periodic measurement of the medication reconciliation process.
"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.
"Patients should keep an accurate list of their medications with them at all times and ask the healthcare provider to repeat their medications and doses to them," Gaunt added.
Consumer tips are also available on the Authority's website on how to minimize your risk of a medication error.
For more information about the breakdowns in medication reconciliation, go to the December Pennsylvania Patient Safety Advisory article "Breakdowns in the Medication Reconciliation Process" on the Authority's website at www.patientsafetyauthority.org. A self-assessment test for clinicians is also available with this article.
The Authority's 2013 December Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:
For the complete 2013 December Pennsylvania Patient Safety Advisory, go to www.patientsafetyauthority.org.
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