Project summary in plain language

Enhancing Drug Therapy Safety in the Medication Process

Evaluation of in-hospital medication errors and development of interventions to reduce errors in the context of unit-dose supply

 

Problem/patient group

The medication pathway in hospitals is complex: from medication history to physician prescribing, preparation and administration by nursing staff, and finally the discharge medication and its documentation in the discharge letter – discrepancies can occur at any of these stages. Each of these inconsistencies can, in the worst case, lead to avoidable harm to patients.

Aim

As part of the implementation of a unit-dose system, where medications are individually packed and labeled per patient, additional measures will be developed to enhance the safety of the medication process.

Implementation

At seven reference wards where the new system is first being introduced, a retrospective baseline assessment is carried out (Phase 1). This phase investigates how often and to what extent unintended medication discrepancies (UMDs) occur – deviations between intended and actually administered medications.

Based on these findings, measures to reduce errors are jointly developed with the involved healthcare professionals. This takes place using a Failure Mode and Effects Analysis (FMEA). The developed interventions are then implemented as the unit-dose system is introduced on the wards.

Finally, the same data collected in Phase 1 is gathered again to evaluate the effectiveness of the implemented measures.

Result

Preliminary findings from phase 1 show that unintended medication discrepancies can affect nearly every patient. Drugs regularly taken at home are especially prone to being incompletely recorded during hospital admission. These omissions can be serious and significantly impact the inpatient course. Particularly concerning: around half of these errors remain undetected throughout the hospital stay – they continue to exist to the discharge letter and thus pose a risk to post-discharge care.

Patient benefit

The findings from phase 1 clearly show: medication errors are not exceptions, but a significant number has systemic causes. With the introduction of unit-dose dispensing and further targeted interventions, we are improving this high-risk process and enhancing medication safety.

 

Image source: Christian Hermann