Can Curatives Kill? Reducing the Risk of Medication Error

An adverse drug event (ADE) is defined as “harm experienced by a patient as a result of exposure to a medication.”¹ The Institute of Medicine says an ADE is “an injury resulting from a medical intervention.”² Like any adverse event, occurrence of an ADE does not necessarily indicate an error or poor quality care. However, adverse drug events account for nearly 700,000 emergency department visits and 100,000 hospitalizations annually.¹

Adverse Drug Events and Medication Errors*

One way a patient can experience an ADE is through a medication error. A medication error can occur at any step in the process, beginning when a clinician prescribes a medication and ending when the patient actually receives the medication. It can be an error of omission or an error of commission.¹ The Institute of Medicine’s report, To Err is Human, describes a medication error as “an error in the process of ordering or delivering a medication, regardless of whether an injury occurred or the potential for injury was present.”² Further, nearly 5% of hospitalized patients experience an ADE, making them one of the most common types of inpatient errors.¹

Potential for Harm

According to the Agency for Healthcare Research and Quality, there are more than 10,000 prescription medications available for clinicians to choose from.¹ The Centers for Disease Control and Prevention (CDC) statistics show the number of drugs ordered or provided to Americans during office visits equals 2.9 billion and 368.5 million during hospital emergency department visits,. Available data also indicates that drug therapy is involved in 73.9% of overall patient office visits and 81.1% of emergency room visits.³ The CDC estimates that 82% of American adults take one medication and 29% take five or more medications.⁴

Additional Risk Factors Associated with Medication Errors

Areas requiring added vigilance due to an increased potential for medication error include:

• Transitions in patient care (e.g., between healthcare providers, discharges from facilities or between levels of care)
• Polypharmacy (e.g., patients who take five or more medications)
• Age-related (e.g., elderly or pediatric patients require closer monitoring)
• Limited health literacy (e.g., lack of understanding medication information, differing names for the same drug, rationale for use, correct dosage, administration, or frequency, etc.)
• Combined use and over-use of over-the counter (OTC) medications, herbal remedies or alternative medications
• Prescribing high-alert medications

Why Reconcile?

Many medication errors are preventable and medication reconciliation is one strategy for reducing the risk of medication error. In a review of closed claims data from the NORCAL Group of companies (March 2014-February 2019), medication errors are a common allegation against physicians. The data shows medication errors as the fifth most frequent and the seventh most expensive allegation against our insured physicians. A number of factors contributed to the medication errors that occurred in these claims, including:

• The patients’ comorbid conditions
• Inadequate patient histories
• Problems with medical record documentation
• Communication problems between providers

These contributing factors are closely tied to conducting medication reconciliation. Data revealed that almost one-quarter of the medication error claims involved these issues that are potentially related to a breakdown in the medication reconciliation process.

Medication reconciliation takes clinical skill and can save lives. The Institute of Health Improvement indicates that the goal of medication reconciliation is to prevent ADEs by creating and maintaining the most accurate list possible of the patient's medications including drug name, dosage, frequency, and route—and using that list to guide therapy.⁵

Medication reconciliation in the office site should be thought of as a patient safety measure and not viewed only as an accreditation function. Using a systematic and formal process with clearly designated responsibilities can improve and streamline the process. Consider the following:

1. Obtain an accurate list of prescribed medications, OTC drugs, herbs, vitamins, and supplements.
2. Verify the list with the patient using other reliable sources when possible: drug vials, patient’s medication list, pharmacy, checking for changes in dosage, routes, frequencies, etc.
3. Reconcile and correct inadvertent discrepancies in the list (e.g., duplicates). This does not necessarily mean the clinician is verifying the appropriateness of the medications or dosages, as that should hopefully have been determined by the prescriber (who should be in a position to make that determination). However, it is important to determine whether any medication that the patient is taking or receiving as a result of your visit or procedure is reconciled. This may require communication, consultation, or coordination with another prescriber. This can also be an opportunity to educate patients on their medication management.
4. Document in the record changes to the medication list (e.g., finalize the list in the electronic health record) and provide a copy to the patient.

Risk Management Recommendations

• Create and maintain a current medication list for all patients.
• Develop a systematic, standardized and formal process for medication reconciliation.
• View medication reconciliation as a patient safety measure that is incorporated into the patient evaluation process by the clinician.
• Understand that medication reconciliation includes reviewing and verifying medication history, clarifying appropriate dosing, frequency, contraindications, and/or interactions; reconciling conflicts; and finalizing changes to the medications in the medical record.
• Keep a heightened awareness of additional risk factors associated with medication errors and ADEs.

References

* NOTE: Statistics will vary based on the definitions and time periods used in the source.

1. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. “Medication Errors and Adverse Drug Events.” Page last updated September 2019.

2. Institute of Medicine. To Err is Human: Building a Safer Health System. 1999.

3. Centers for Disease Control and Prevention. “Therapeutic Drug Use.” Page last reviewed January 19, 2017.

4. Centers for Disease Control and Prevention. “Medication Safety Basics.”

5. The Institute for Healthcare Improvement. “Medication Reconciliation to Prevent Adverse Drug Events.”

Additional Resources

Department of Health and Human Services Agency for Healthcare Research and Quality:

• “Medication Reconciliation Victory After an Avoidable Error”
• E‐prescribing: E for error?