Critical Medication Error Statistics
According to the U.S. Food and Drug Administration:
- 54-67% of all admitted patients had at least one error that has the potential to cause harm
- More than half of all medication errors occur at transitions of care
- 8%-25% median medication error rate during medication administration
Medication Reconciliation is not accurate on admissions.
Situation
According to the FDA, medication errors cause at least one death every day and injure approximately 1.3 million people annually in the U.S. While hospitals do their best to maximize patient care and safety, preventable mistakes—such as duplicate orders and administrations, as well as poor patient communication—are, unfortunately, industrywide realities that may exacerbate this problem, putting hospitals at risk of fines and legal fees, and worse, serious patient harm.
Through its partnership with CompleteRx, a 186-bed hospital in New York state set out to address this issue at its own hospital, where a number of challenges—including confusing order sets due to outdated or incomplete patient medication histories—were contributing to errors and inefficiencies.
Solution
In response to these challenges, CompleteRx developed the Medication Reconciliation Technician Program as a first line of defense against medication errors at the hospital and to significantly improve communications about medications (HCAHPS). Among other things, the new program:
Key Program Components
Designated Pharmacy Technician
- Designates a pharmacy technician—dually trained in medication reconciliation and traditional pharmacy functions—to research and enter all medications admitted patients are currently taking into the hospital’s Meditech system (previously, there was a diffusion of responsibility across physicians, nurses and pharmacists, leading to gaps and inefficiencies).
Decentralized Pharmacy Services
- Decentralizes the pharmacy, strategically inserting pharmacy technicians into the workflows of different departments to ensure error reduction, while maintaining throughput. With their new dedicated resource, nurses and physicians are able to take advantage of voluntary pharmacy consults—particularly for vulnerable populations—providing patients and their families direct contact with pharmacists in an effort to maximize medication adherence and minimize at-home errors.
Standardized Primary-Source Verification
- Standardizes primary-source verification, previously conducted sporadically and only in the patient care team’s elusive spare time, in which pharmacy technicians may confirm the patient’s account of his or her medication history directly with physicians to ensure accuracy. This approach also promotes coordinated patient care across nurses, physicians and emergency personnel, improving the group’s ability to catch medication errors before they occur.
This approach promotes coordinated patient care across nurses, physicians and emergency personnel, improving the group’s ability to catch medication errors before they occur.
Results
CompleteRx performed a two-week pilot study to gain approval for the Medication Reconciliation Technician Program. After conducting a baseline assessment of the hospital’s current processes and then implementing the proposed program, the team saw a dramatic increase in accuracy, from 44% to 88%.
Most importantly, these improvements—which were verified by an independent auditor—eliminated the effect of medication errors on patient care (i.e., residual errors were minor and didn’t change patients’ treatment course). Shortly after the audit, CompleteRx worked to officially launch the Medication Reconciliation Program which continues to maintain its efforts to reduce medication errors today.
Key Performance Improvements
This new program saw a major improvement in multidisciplinary approach to patient care, including a 65% increase in communications about medication and a 98th percentile HCAHPS ranking in patient satisfaction on discharge planning.
Audit Results Comparison
MetricAudit 1 (Current Process)Audit 2 (Pharmacy Involvement)Number of Patients Seen7471Number of Reconciliations Verified6152Number of Errors349Accuracy Rate27/61 (44%)43/52 (83%)Patient Impact15/34 (44%)0
Error Breakdown
Audit 1 Breakdown:
- Total Errors: 34
- Serious: 16
- Minor: 18
- Patient Impact Errors: 15 (13 serious, 2 minor)
Audit 2 Breakdown:
- Total Errors: 9
- Serious: 1
- Minor: 8
