Sharing responsibility for medication safety
This case illustrates the complex interaction of hospital, physician’s office, pharmacy, and patient’s home in causing or preventing medication errors. Fostering better communication with patients and improving patient medication records become even more important in this day of internet website purchases and mail-order pharmacies.
However, creating the common medication record is insufficient to assuring patient safety. The medication record must be reconciled with the patient’s behavior, including actual use of prescribed, over the counter, herbal, homeopathic, home, and other alternative remedies.
Communication must be clear not only while the patient is being cared for, but also when care transitions occur. The patient’s health literacy, values about care, dependence on others, and cultural beliefs are known to influence how patients actually use medications.
Better technology systems would certainly help detect medication errors. But a non-technology solution is available now. In this case, the patient’s poor health literacy was certainly evident in his lack of knowledge of the names of medications and in not understanding the duplication of drugs he was prescribed. But what about the medication literacy of the physician and nurse professionals in this case? Explaining the unfamiliar (and misspelled) drug to the patient could have prevented the drug duplication.
This patient indicated his trust in his primary care physician. This is cornerstone to the therapeutic relationship. However, this trust was not adequate to prevent this error from occurring or from the patient experiencing harm. Patient advocate organizations, such as the National Council for Patient Information and Education, or the Agency for Healthcare Research and Quality, suggest that patients will best be protected from harm by becoming an active participant on the health care team. Safety is achieved through ongoing and appropriate communication with patients to prevent harm. Pharmacists do contribute to resolving many medication safety issues for patients. The practice of pharmacy includes comprehensive medication history taking and documentation to maintain a patients medication profile.
For many patients, the pharmacist is a primary provider who communicates with them fairly regularly about medicines, and maintains medication lists. Many pharmacists routinely provide patients with medication list wallet cards, conduct comprehensive “brown bag” medication reviews, and maintain an active medication profile, including the over the counter and alternative remedies that patients describe or purchase from the pharmacy.
With the Medicare Modernization Act of 2003 came the federal prescription drug benefit, covering some of the costs to elderly patients who elect a prescription drug benefit provider who chooses to provide drug therapy monitoring services. Many pharmacists are expanding medication management services to support the patient with needed communication and counseling to prevent harm and improve safety. These will be important additions to the health care safety needs of patients.
Even with the system improvements we have described above, medication safety remains a shared responsibility between health care providers, patients, and health care organizations. A few guides have been published and are available free of charge to assist patients in knowing what they can do to help themselves with proper medication use and safety. These guides offer some practical tools and advice for patients to build patient knowledge about what to expect. Patients who use these tools will better assure safe practices and minimize harm:
Your Medicine: Play It Safe. Patient Guide. AHRQ Publication No. 03-0019, February 2003. Rockville, Md: Agency for Healthcare Research and Quality; Bethesda, Md: National Council on Patient Information and Education; 2003. Available at: www.ahrq.gov/consumer/safemeds/safemeds.htm.
20 Tips to Help Prevent Medical Errors. Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Rockville, Md: Agency for Healthcare Research and Quality; 2000. Available at: www.ahrq.gov/consumer/20tips.htm.
Quick Tips—When Getting a Prescription. AHRQ Publication No. 01-0040c, May 2002. Rockville, Md: Agency for Healthcare Research and Quality; 2002. Available at: www.ahrq.gov/consumer/quicktips/tipprescrip.htm.
Kimberly A. Galt, PharmD
Associate Dean for Research
Professor of Pharmacy Practice
Director, Creighton University Health Services Research Program (CHRP)
Creighton University
Omaha, Neb
The last two issues under “Latent Failures” regard medication name usage. In a free market system, multiple organizations are permitted to market the same active ingredient under their own brand name or under the generic name. If prescribers and pharmacies were permitted to use generic names only, this could have helped avoid the confusion that occurred in the present case. But, again, the legislation necessary to make this happen would likely be opposed by industry. A possible compromise would be to require prominent identification of the generic name on medication bottles and medication lists (whether in paper or electronic form), as well as the drug’s indication so that duplications are easier for both patients and health care workers to identify.