Patient safety/original research
Medication Errors Recovered by Emergency Department Pharmacists

https://doi.org/10.1016/j.annemergmed.2009.10.012Get rights and content

Study objective

We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors.

Methods

We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated.

Results

We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors.

Conclusion

ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.

Introduction

Emergency departments (EDs) face special challenges in their mission of providing high-quality, efficient, and safe care to a diverse population of patients. Medical errors, and more specifically medication errors, are common in EDs and are often severe.1, 2 This is not surprising because more than three fourths of ED visits are associated with medication administration or prescribing, representing more than 210 million medication encounters annually in the United States.3

The “perfect storm”4 of a stressful environment caused by crowded EDs, increasing numbers of admitted patients boarding in the ED, and understaffing results in a high-risk setting for medication errors.5 Furthermore, there are challenges specific to safe ED medication use, including point-of-care orders, common use of verbal orders, incomplete medical records, multitasking with frequent interruptions and distractions, and the high prevalence of information gaps for patients.6, 7

A recent systematic review of clinical pharmacists participating in inpatient care provides strong evidence that inpatient clinical pharmacists reduce preventable adverse drug events caused by medication errors,8 especially in medical ICUs.9 Pharmacists in EDs may be able to play a role similar to that in ICUs. Besides their traditional roles, including medication order review and toxicologic consultations, ED and ICU pharmacists have the opportunity to participate in decisionmaking before medications are ordered or administered.10 Additionally, dedicated ED pharmacists may have the necessary time and access to clinical data not immediately available to physicians in the ED. However, to date only limited data have been available on the effects of ED pharmacists on medication safety.11, 12, 13 Pharmacist time is expensive, and there is a national shortage of pharmacists so that if pharmacy staffing of EDs is to be justified, more data are needed to demonstrate the effects of ED pharmacists on safety, quality, and efficiency.

Our primary objective was to assess the effect of ED pharmacists on patient safety with regard to recovery of potentially harmful medication errors. Our secondary objectives were to characterize the error types and the nature of the pharmacist interventions used to recover errors.

Section snippets

Study Design

We performed a prospective cross-sectional observation study of pharmacists who recovered medication errors in 4 EDs between August and December 2008. Consent for observation was obtained from the ED pharmacists. The study was approved by the Human Research Committees at all sites.

Setting

The study was conducted in 4 academic medical center EDs located in the Northeast, Southeast, Midwest, and West. The participating EDs are trauma Level I centers and ranged widely in size and annual visits (Table 1).

Characteristics of Study Subjects

We observed 12 ED pharmacists, at the 4 different sites, with an average of 3.3 years of hospital pharmacy experience (range 1 to 8 years). Demographics for patients with recovered medication errors, including reason for ED visit, are provided in Table 2.

We conducted 226 observation sessions during 787 hours of observation (Table 2). Researchers observed pharmacists reviewing 17,230 medications for 6,471 ED patients (Table 3). During observation sessions (mean duration of 3.5 hours), we

Limitations

Our study was conducted in academic medical center EDs, and our findings may not be generalizable to smaller or nonteaching EDs. Our study was a convenience sample conducted during some of the busier times of day for ED pharmacists. The total number of recovered medication errors per 40 hours of observation may not be representative of the weekly work schedule of an ED pharmacist. The potential limitation of conducting our study in EDs with computerized physician order entry is mitigated by the

Discussion

Our study is one of the largest multicenter observational studies of ED medication safety. We found that pharmacists frequently reduced the potential of patient harm from medications that were ordered or administered by ED staff. Most medication errors were caught before reaching the patients, and about half were potentially serious or life threatening. Extrapolating our results to a 40-hour workweek covering busy ED activity times in a large academic ED, about 25 potentially harmful medication

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    Supervising editor: Robert L. Wears, MD, MS

    Author contributions: JMR, WC, JDS, RS, JP, RJ, AS, SR, and DWB conceived the study, designed the trial, and obtained research funding. JMR, WC, AE, KM, RS, RA, JP, RJ, AS, and SR supervised conduct of the data collection. JMR, CAS, AE, KM, CAS, DL, RS, RA, and JP supervised the observations and primary data collection, including quality control. JMR, JDS, RS, JP, and AS participated in the incident reviews. JMR, WC, JDS, CAS, RS, JP, and AS analyzed and interpreted the data. JMR drafted the article, and all authors contributed substantially to its revision. JMR takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This study was supported by a grant from the American Society of Health-Systems Pharmacists Research and Education Foundation.

    Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com.

    Reprints not available from the authors.

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    Please see page 514 for the Editor's Capsule Summary of this article.

    Publication date: Available online December 11, 2009.

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