Johns Hopkins Study Recommends Training of Nurse-Pharmacist Teams to Review Patient Drug Regimens, as a Way to Prevent Medication Errors

360px-Intravenous_attempt.jpgSerious complications and injuries can result from discrepancies between the medications patients take at home, the medications they receive in the hospital, and the medications they take home with them. To prevent such medication errors, a recent study out of Johns Hopkins recommends that hospitals train teams of nurses and pharmacists to reconcile patients’ medication lists. Such teams could better ensure that patients receive consistent medications and dosages, at a lower cost to both the hospital and the patient, thus improving overall health and safety for hospital patients.

The Journal of Hospital Medicine published the study, entitled “Nurse-pharmacist collaboration on medication reconciliation prevents potential harm,” in its May/June 2012 issue. The purpose of the study was to test how “medication reconciliation” could help prevent “adverse drug effects” (ADEs). The study involved over five hundred patients at a “1000 bed urban, tertiary care hospital” from January 2008 through March 2009. Nurses would conduct an interview with patients to obtain a home medication list (HML), outlining all medications regularly taken by the patients. Patients often forgot or otherwise omitted some medications during this process, or were unable to remember the name or dosage of a drug. Some patients could only provide a description of the drug’s appearance, and many were not certain what condition a particular drug treated. Discrepancies between the medications a patient was actually taking and those they received during treatment and upon discharge occurred in forty percent of hospital visits, according to the researchers.

The nurse-pharmacist teams participating in the study performed what chief researcher Dr. Leonard Feldman called “detective work.” They would conduct a second interview with the patients to review their medications, and compare the patient’s HML to records from previous hospital visits. In some cases, they would contact patients’ families, primary care physicians, and pharmacists to get medication information. They would also compare the HML to the patient’s admission orders, noting discrepancies. They separated intentional discrepancies from ones that were inadvertent, and therefore potentially harmful. The teams rated the unintentional discrepancies on a “potential harm scale” of 1 to 3 (3 being most harmful).

Out of 563 total patients, 225 of them, or forty percent, had unintentional discrepancies in their admission or discharge medication orders. Twenty-nine percent of the total number of patients, had unintentional errors rated 2 or 3 on the potential harm scale. The researchers calculated the cost of finding one discrepancy with the potential to cause an ADE as $113.64, and stated that their process would need to find one discrepancy out of every 290 patient visits in order to be cost-effective. Their process, the study concluded, spotted eighty-one ADEs for every 290 visits.

Hospitals, doctors, nurses, and pharmacists owe a duty of care to take all reasonable and necessary steps to ensure that patients receive proper treatment and the correct medications. Nurses and pharmacists in particular have a duty to make certain that patients receive the correct medications in the correction dosages, in accordance with a doctor’s orders.

The Maryland pharmacy error attorneys at Lebowitz & Mzhen can assist you if you have been injured by drugs prescribed, dispensed, or administered incorrectly. Contact us today online, or by calling (800) 654-1949 to see if you may recover damages.

More Blog Posts:

Hospital Uses RFID Tags to Keep Track of Emergency Room Drugs, Pharmacy Error Injury Lawyer Blog, July 26, 2012
Study Suggests that Electronic Medical Records Can Reduce Error Rates, Pharmacy Error Injury Lawyer Blog, July 5, 2012
Study Finds Use of Interpreters in Hospital Emergency Departments Reduces Medication Errors Almost by Half, Pharmacy Error Injury Lawyer Blog, June 28, 2012
Photo credit: ‘Intravenous attempt’ by Rjgalindo (Own work) [Public domain], via Wikimedia Commons.

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