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Drug Errors and Related Interventions Reported by United States Clinical Pharmacists: The American College of Clinical Pharmacy Practice-Based Research Network Medication Error Detection, Amelioration and Prevention Study

Authors

  • Grace M. Kuo,

    Corresponding author
    1. Family & Preventive Medicine, School of Medicine, University of California, San Diego, California
    • Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, California
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  • Daniel R. Touchette,

    1. Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
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  • Jacqueline S. Marinac,

    1. American College of Clinical Pharmacy, Lenexa, Kansas
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  • for the American College of Clinical Pharmacy Practice-Based Research Network Collaborative


  • This project was funded by the Frontiers Fund of the American College of Clinical Pharmacy (ACCP) Research Institute.
  • Preliminary results of this study were presented as a poster at the ACCP annual meeting, Pittsburgh, Pennsylvania, October 18, 2011.

For questions or comments, contact Grace M. Kuo, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, 9500 Gilman Drive, MC 0719, La Jolla, CA 92093-0719; e-mail: gmkuo@ucsd.edu.

Abstract

Objective

To describe and evaluate drug errors and related clinical pharmacist interventions.

Design

Cross-sectional observational study with an online data collection form.

Setting

American College of Clinical Pharmacy practice-based research network (ACCP PBRN).

Participants

A total of 62 clinical pharmacists from the ACCP PBRN who provided direct patient care in the inpatient and outpatient practice settings.

Intervention

Clinical pharmacist participants identified drug errors in their usual practices and submitted online error reports over a period of 14 consecutive days during 2010.

Measurements and Main Results

The 62 clinical pharmacists submitted 924 reports; of these, 779 reports from 53 clinical pharmacists had complete data. Drug errors occurred in both the inpatient (61%) and outpatient (39%) settings. Therapeutic categories most frequently associated with drug errors were systemic antiinfective (25%), hematologic (21%), and cardiovascular (19%) drugs. Approximately 95% of drug errors did not result in patient harm; however, 33 drug errors resulted in treatment or medical intervention, 6 resulted in hospitalization, 2 required treatment to sustain life, and 1 resulted in death. The types of drug errors were categorized as prescribing (53%), administering (13%), monitoring (13%), dispensing (10%), documenting (7%), and miscellaneous (4%). Clinical pharmacist interventions included communication (54%), drug changes (35%), and monitoring (9%). Approximately 89% of clinical pharmacist recommendations were accepted by the prescribers: 5% with drug therapy modifications, 28% due to clinical pharmacist prescriptive authority, and 56% without drug therapy modifications.

Conclusion

This study provides insight into the role clinical pharmacists play with regard to drug error interventions using a national practice-based research network. Most drug errors reported by clinical pharmacists in the United States did not result in patient harm; however, severe harm and death due to drug errors were reported. Drug error types, therapeutic categories, and clinical pharmacist interventions varied between the inpatient and outpatient settings. Nearly half of reported errors were prevented by clinical pharmacists before the drugs reached the patients. The majority of clinical pharmacist recommendations were accepted by prescribers.

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