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Study: Comparing pharmacists and nurses in med reconciliation

The US FDA approves 25 new drugs per year representing some 400 new formulations.

An article in Pharmacy Practice News last October, 2010 described a study conducted at the Medical Center of Aurora in Colorado that compared the accuracy and completeness of admission medication histories recorded by nurses and pharmacists respectively.

The study tracked 100 adults admitted to the emergency department over three months, who were able to respond to questions about their medications.  The ED nurse initially documented the patients home meds, apparently as part of the triage/assessment.  This was followed by an ED pharmacist interviewing all patients awaiting inpatient beds and updating the home med list originally collected.  On admission to the floor, a nurse was charged with reviewing the updated home medication list, interview the patient for a third time and document any changes.  Finally, the ED pharmacist would review all three iterations of the med history and follow up on any discrepancies by re-interviewing the patient or contacting the patient’s family, physician or community pharmacy for clarification when necessary.

In terms of the average number of meds documented per patient at each phase of admission, the ED nurse collected 3.87, the flor nurse 4.18 and the pharmacist 7.48 meds per patient.  The study found that omissions were the most common error and that vitamins and over the counter products were most often ommitted.  It also found that the pharmacist collected the most accurate med histories.

The Five Rights of Medication Administration

If your organization is experiencing difficulty maintaining consistent medication administration processes, may I recommend the following YouTube instructional video on the subject (for it’s entertainment value). Unfortunately, the producer of this video omitted the sixth Right… Documentation. Hopefully he will incorporate it into a future Club Remix version. Enjoy!

Click this link to view the Five Rights of Medication Administration Rap Video

Five Rights Rap Video





326 million e-prescriptions per year and counting…

Electronic prescription usage increases.

A story in the Seattle Times this week sheds some light on the scale of adoption of electronic prescripton writing in the outpatient world.

The figures cited from New Jersey indicate that just 20% of physicians are using electronic prescribing systems today and that between 2007 and 2009 the percentage of electronic prescriptions in that state jumped from 190 million to 326 million.

It should be noted that adoption of e-prescribing can be an arduous process, requiring a thorough review of prescribing practices, practice-appropriate device selection, thoughtful build and extensive user training to make things go smoothly and hopefully to achieve the safety benefits of an e-prescribing system.

Read the original Seattle Times story.

Death of three patients at British hospital linked to suspected tampering of Saline vials

Stepping Hill Hospital

Administrators, Doctors, Nurses and Pharmacists are always devastated when patients in their care are harmed due to medication errors, or worse, medication tampering/contamination.  What appears to have been a case of suspected tampering of 0.9% Sodium Chloride vials (Saline) has resulted in the deaths of three patients aged 84, 71 and 44 at Stepping Hill Hospital in Stockport, UK.  Eleven other patients have suffered adverse effects as a result of this suspected tampering. The BBC reports that all patients involved had lower than normal blood glucose levels.   This of course points to the potential deliberate or accidental contamination of the saline with insulin.   Again, however, in the absence of more detailed reports it is too early to tell what has actually occurred.

Stepping Hill’s administrators, department directors, managers and staff are undoubtedly struggling to determine what happened at this point and it is hoped they will share their findings with the rest of the medical community so that we can all learn from this tragic event and implement the necessary safeguards to prevent a recurrence of this event in the future.

Patientsafetyhub.com will continue to follow this story.  In the meantime, our prayers are with the deceased and their families.  Click these links to read what the BBC and the Guardian newspaper have been reporting.

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Patient Safety Hub is a not-for-profit endeavor dedicated to generating discussion, sharing best practices and evaluating ideas designed to keep patients safe in all healthcare settings. It also provides a forum for patients to share their experiences with medical errors.

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