Clinical pharmacists, paired with technology, catch dozens of potentially harmful medication errors

Medication errors are extremely common and have the potential to cause significant patient harm during or after a healthcare interaction. Research shows that up to 70 percent of patients admitted to hospitals have at least one error on their medication lists – and more than half of these mistakes could result in an adverse effect for that individual. 

Equipping hospital care providers and clinical pharmacists with effective technology to identify discrepancies in medication lists and proactive correct any issues can keep patients safer and avoid negative outcomes, a new study published in PLOS ONE shows.   

Researchers from McLean Psychiatric Hospital used a medication history analytics platform to review the records of 72 patients between August of 2019 and February of 2020. They found 82 medication errors among these patients and determined that 74 of these errors may have produced harm if not corrected through appropriate interventions. 

The most frequent medication errors were related to incorrect dosages (33 percent), omission of current medications (26 percent), frequency of dosage (19 percent), and formulation of medication (12 percent). 

“At a teaching hospital like McLean, there are interns and residents involved in patient care who are still learning about admitting patients,” said Colin Banas, MD, an author of the study and the Chief Medical Officer at DrFirst, McLean’s technology partner for the research.   

“That means things can get missed on occasion, so it’s a good idea to identify where issues can occur and get proactive about closing those gaps.”   

“If a clinician doesn’t have a correct medication list up front, it’s very easy to make inaccurate decisions about that patient throughout their stay. Inaccurate information at the start can create a prescription cascade with errors that have the potential to perpetuate even after discharge, which is why it’s so important to use analytics and expert clinical pharmacists to review medication lists quickly and accurately.” 

The role of clinical pharmacists in preventing medication errors 

Clinical pharmacists are vital but underappreciated members of the care team, Banas asserts.   

“We’re finally seeing more recognition of what pharmacists are able to do and an expansion of what they are permitted to do,” he said. “Pharmacists have always been the unsung heroes of the care team.  The study really highlighted the need to support these professionals with enhanced technical tools, because the research identified a lot of errors that could have resulted in some degree of harm to the patient if they hadn’t been caught.” 

In the study, patients were taking an average of 9.2 medications prior to admission and experienced an average of 8.4 different medical problems.   

McLean is a psychiatric hospital, so many of the medications and medical diagnoses were related to psychiatric conditions. However, errors also occurred with non-psychiatric medications, potentially jeopardizing the patients’ broader care plans. In addition to antidepressants, anticonvulsants, and antipsychotics, the team identified errors in medications used for asthma treatment, cardiovascular conditions, and reproductive health.  

“Clinical pharmacists know the right questions to ask when doing medication reviews, and they can spot errors very quickly because their whole professional training is devoted to managing medications,” Banas said. “That’s even more important in specialized care environments, where providers are largely focused on the conditions they treat and may not be as well-versed in medications for other medical issues.” 

Unfortunately, just like many other types of providers, the nation is experiencing a shortage of pharmacists and pharmacy technicians to support medication management across a variety of healthcare settings. The shortfalls have been most noticeable for consumers in the retail pharmacy environment, but hospitals and health systems are feeling the lack of qualified staff, as well. 

“We need technology tools to help make up for those shortfalls as best we can,” Banas stated.  “Those tools need to provide full visibility into pharmacy claims and dispensing histories, as well as all the available medication lists in the EMR.” 

Creating a data-driven culture of safety to avoid patient harm 

Health systems are extraordinarily complex, and leaders must acknowledge that mistakes will happen at some point in the patient care process, Banas says. The key to mitigating harm is creating a culture where staff members are engaged, encouraged, and supported to bring those issues into the light, discuss what went wrong, and leverage organizational resources to fix the gaps. 

“Safety starts from the top down with a culture of non-punitive, collaborative transparency,” he said. “Staff members must be empowered and supported to report potential safety events, whether they are near-misses or actual harm has occurred. Organizations need to develop the mechanisms to have these conversations, learn from them, and return those lessons into the system so that they can continuously improve and keep patients safer in the future.”  

Analytics tools and improved data interoperability, along with staff fully trained to use these technologies, are crucial for developing this safety-first culture.  

“We need to dramatically improve the information we’re starting with, and we can do that if we have digital solutions that aggregate as much data as possible and present the data to clinicians in an easily consumable format,” he concluded.   

“Technology can get us 90 percent of the way there so that when people are discussing medications with patients and making changes or updates to medication lists, they are starting from the best possible position and are able to avoid harmful events during the patient’s stay and after they return to their community.” 

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.