Risk goes up when pharmacy closes, but what is solution?
The risk of a medication error rises sharply when a hospital's pharmacy is closed, according to a report by Michael J. Gaunt, PharmD, senior patient safety analyst with the Pennsylvania Patient Safety Authority in Harrisburg. His recent study found that the incorrect drug was retrieved from an automated dispensing cabinet or night cabinet in 82.3% of wrong-drug events.1
Between June 2004 and September 2010, Pennsylvania hospitals submitted to the Pennsylvania Patient Safety Authority 519 medication error reports that implied an event occurred while the pharmacy department was closed, the report says. The most common types of medication errors reported included wrong-drug events, drug omissions, and prescription or refill delays. The predominant medications associated with these reports were warfarin sodium, hydration solutions, insulin, guaifenesin, and vancomycin.
In 28.7% of drug omission events, the medication was not available to the nurse to administer, which led to an omission. Gaunt's report suggests strategies to prevent errors when the pharmacy is closed, such as:
providing a limited supply of medications to be used for urgent medication orders;
standardizing processes for accessing medications when the pharmacy is closed to reduce variability and opportunity for error;
establishing a forcing function error reduction strategy to make the allergy reaction selection a mandatory entry in the organization's order entry systems for prescribers and pharmacists.
A 24-hour pharmacy is always preferable, but not always economically possible, says Marianne F. Ivey, PharmD, MPH, FASHP, associate professor at the University of Cincinnati (OH) in the Pharmacy Practice and Administrative Sciences. She has worked as vice president of pharmacy services at a system of eight hospitals, some of which smaller and could not afford a 24-hour pharmacy. In those cases, she says, one solution was to have the 24-hour pharmacy at a larger facility act as the after-hours review for a smaller facility where the pharmacy was closed.
"They were connected electronically, so there could be prospective review of orders," Ivey says. "Today's patients are sicker than ever, which means more complicated therapies. All of our nurses wanted the assurance that a pharmacist was checking those orders at night."
Other hospitals have restricted off-hours cabinet access to nurses with special training in medication safety, or nurses at a certain level of training such as a registered nurse, Ivey notes.
Technology also is cited as the potential solution by David Kile, director of continuing education and professional development at Albany (NY) College of Pharmacy and Health Sciences and longtime director of pharmacy at a New York hospital. With modern technology, hospitals can improve on the older solution of having a pharmacist on call to address difficult prescription orders. "It's now possible that a pharmacist could log into the hospital's information system, look at the patient, see the order, and process that order from home," Kile says. "This is a step above calling the pharmacist and waking him or her up several times a night. You can have a pharmacist on duty, in effect, at home to review these orders as they come in."
Another option, Kile says, is to contract with a company that will provide after-hours pharmacy review, which can be pricey but still less expensive than a 24-hour pharmacy.
"The break point is about 200 to 300 beds," Kile says. "Those hospitals should be seriously considering a 24-hour pharmacy."
1. Gaunt MJ. Medication errors: When pharmacy is closed. Pa Patient Saf Advis 2012; 9(1):11-7.
Marianne F. Ivey, PharmD, MPH, FASHP, Associate Professor, University of Cincinnati (OH), Pharmacy Practice and Administrative Sciences. Telephone: (513) 558-4131. Email: firstname.lastname@example.org.
David Kile, Director of Continuing Education and Professional Development, Albany (NY) College of Pharmacy and Health Sciences. Telephone: (518) 694-7346. Email: email@example.com.