New medication errors study shows need for oversight
UC pharmacy researchers call for action on medication errors reporting
Remember the last time you picked up a prescription at a community pharmacy. How closely did you look at the product you received?
Did you compare the name on the label to make sure it was yours? Did you check to see if the number printed on the tablet or capsule (all prescription pills have numbers) matched the number on the label? Did you look at the dosage?
Some might ask: Why do this? Isn’t it the pharmacist’s job to fill the prescription correctly?
Yes, it is, however, pharmacists are human, and humans make mistakes; an estimated 1.5 million medication errors in the U.S. annually, according to a health policy brief published by pharmacy researchers at the University of Cincinnati. The brief also cites an estimation of two prescription errors per 2,000 prescriptions filled by a typical community pharmacy in the U.S. every week.
Daily reminder containers are often used to keep medications in order; however, it's also necessary to be sure you have the correct medications from the pharmacy.
The brief, sent to the National Association of Boards of Pharmacy (NABP) this week, calls attention to what UC researchers found in a new study; that, despite NABP recommendations in 2007, most states still do not have continuous quality improvement regulations in place for the reporting of medication errors which occur at community pharmacies across the country.
Ana Hincapie is an assistant professor of pharmacy practice and administrative sciences at UC's James L. Winkle College of Pharmacy. Dr. Hincapie has an established background in medication safety and quality improvement in health care and has co-authored two book chapters related to medication safety and quality improvement. .
The study, led by Ana Hincapie, an assistant professor of pharmacy practice at UC’s James L. Winkle College of Pharmacy, describes medication errors as “quality-related events,” one of which is when the patient receives an incorrect drug, dose or quantity and the other when errors are caught before dispensing (i.e. near misses).
While institutions such as hospitals and compounding facilities are mandated to report medication errors and have a continuous quality improvement program in place, most states do not require the same of community pharmacies. According to the UC study, only 16 states have continuous quality improvement regulations for community pharmacies and only four more states are in the process of exploring implementation.
“We hope our work incentivizes states to share lessons learned and take the next steps in implementing continuous quality improvement regulations in community pharmacy practice,” says Hincapie who has an established background in medication safety and quality improvement in health care.
By contrast, the study points to Canada as a model for continuous quality improvement and the reduction of quality-related events in community pharmacies. Nearly every Canadian province has implemented these changes to pharmacy practice across the entire country.
“Our analysis, as highlighted in this policy brief, demonstrates the slow adoption of patient safety practices by state boards of pharmacies across the U.S.,” says the study’s co-author, Neil MacKinnon, dean of UC’s College of Pharmacy.
MacKinnon, a native of Canada, has been researching medication errors for over two decades and was instrumental in bringing the patient safety concern to the forefront there.
There is no time to wait, he says: “The evidence is clear, the need is great and the time to adopt these practices is now.”
Fourth-year medical biomedical sciences student Justin Austin contributed to this research.
Featured image at top of customers in a pharmacy getting perscriptions filled. Photo/Tbel Abuseridze/Unsplash.
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