Pharmacist Institutes Program of Double-Checking Discharge Papers, Cuts Hospital Pharmacy Errors to Near Zero

The hospital pharmacy services director at Minnesota’s Hennepin County Medical Center, Bruce Thompson, noticed several years ago that his staff would often discover medication errors when patients returned to the hospital after treatment. The Minneapolis Star-Tribune recounted the story of a patient who left the hospital after a kidney transplant with incorrect dosage instructions for the prescribed antibiotics. The hospital discharged a patient who had been treated for a pulmonary embolism without an essential blood thinner. Thompson wondered how common such mistakes were at the hospital, so he enlisted some colleagues to review thirty-seven patients who had been discharged from the hospital to area nursing homes during a three-month period at the end of 2008 and beginning of 2009

Thompson discovered that only three of the thirty-seven cases he reviewed had no problems. That meant an error rate of ninety-two percent, with about a third of the errors deemed “likely harmful.” The most common errors included prescriptions with incorrect dosages and duplicates or omissions of medications at discharge.

To reduce the surprisingly-high rate of errors, Thompson and the hospital administration had pharmacists review all patients’ discharge orders before the patients left the hospital. This allowed the pharmacy one last opportunity to spot mistakes and notify the patient’s doctor to resolve the problem.

According to the hospital’s report, the rate of errors dropped to almost none nine months after they started pre-release review by pharmacists. This also reduced the hospital’s readmission rate to around five percent, meaning far fewer patients were returning to the hospital for additional treatment after their discharge.

The Institute for Safe Medication Practices, which offers education and support to healthcare organizations, gave Hennepin County Medical Center one of its “Cheers” Awards in 2010. This award recognizes people, organizations, or businesses that “have set a superlative standard of excellence” in preventing errors relating to medication errors or drug incidents.

The improvement in patient safety in the hospital pharmacy is welcome news, although it is just one part of a hospital’s operations, and mistakes can occur almost anywhere. Hennepin County Medical Center ranked relatively low, for example, in a review of Minneapolis-area hospitals conducted by the U.S. Department of Health and Human Services that looked at infections resulting from central lines used in critically ill patients. This is a relatively rare procedure, and the hospital still performed above the national average. It nevertheless demonstrates that medication errors and infections do not occur solely in the pharmacies or upon discharge.

To the greatest extent possible, patients and their families or representatives should communicate closely with doctors and pharmacists to ensure that they understand their treatment and prescribed medications. Hospitals should also encourage doctors and pharmacists to communicate with one another. This remains the best way to prevent errors in the first place. Errors cannot be stopped entirely, but positive steps to improve patient safety ought to be encouraged.

The Maryland pharmacy error attorneys at Lebowitz & Mzhen are skilled at assessing liability and damages for injuries caused by medication errors and helping their clients obtain compensation. For a free consultation to review your case, contact a lawyer online or at (800) 654-1949.

More Blog Posts:

Drug Confusion Causes Eye Injury, $1 Million Lawsuit, Pharmacy Error Injury Lawyer, January 12, 2012
Hospital Patient Mistakenly Given Drug Used in Executions, Pharmacy Error Injury Lawyer, December 7, 2011
Government Promotes Communication Between Doctors and Patients to Reduce Pharmacy Errors, Pharmacy Error Injury Lawyer, November 28, 2011

Contact Information