Medication Errors Recovered by Emergency Department Pharmacists

Medication Errors Recovered by Emergency Department PharmacistsJeffrey M. Rothschild, MD, MPH
AffiliationsDivision of General Medicine, Brigham and Women's Hospital, Boston, MAHarvard Medical School, Boston, MAAddress for correspondence: Jeffrey M. Rothschild, MD, MPH, Division of General Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120-1613;
617-732-4825
617-732-4825
fax 617-732-7072

, William Churchill, MS, RPh
Affiliations Pharmacy Department, Brigham and Women's Hospital, Boston, MA
, Abbie Erickson, PharmD
Affiliations Pharmacy Department, Brigham and Women's Hospital, Boston, MA
, Kristin Munz, PharmD
Affiliations Pharmacy Department, Brigham and Women's Hospital, Boston, MA
, Jeremiah D. Schuur, MD, MHS
Affiliations Harvard Medical School, Boston, MADepartment of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
, Claudia A. Salzberg, MS
Affiliations Division of General Medicine, Brigham and Women's Hospital, Boston, MA
, Daniel Lewinski, PhD
Affiliations Division of General Medicine, Brigham and Women's Hospital, Boston, MA
, Rita Shane, PharmD
Affiliations Pharmacy Department, Cedar-Sinai Medical Center, Los Angeles, CA
, Roshanak Aazami, PharmD
Affiliations Pharmacy Department, Cedar-Sinai Medical Center, Los Angeles, CA
, John Patka, PharmD
Affiliations Pharmacy Department, Grady Health System, Atlanta, GA
, Rondell Jaggers, PharmD
Affiliations Pharmacy Department, Grady Health System, Atlanta, GA
, Aaron Steffenhagen, PharmD
Affiliations Pharmacy Department, University of Wisconsin Hospital and Clinics, Madison, WI
, Steve Rough, MS, RPh
Affiliations Pharmacy Department, University of Wisconsin Hospital and Clinics, Madison, WI
, David W. Bates, MD, MSc
Affiliations Division of General Medicine, Brigham and Women's Hospital, Boston, MAHarvard Medical School, Boston, MA

Study objective
We assess the impact of emergency department (ED) pharmacists on reducing potentially harmful medication errors.

Methods
We conducted this observational study in 4 academic EDs. Trained pharmacy residents observed a convenience sample of ED pharmacists' activities. The primary outcome was medication errors recovered by pharmacists, including errors intercepted before reaching the patient (near miss or potential adverse drug event), caught after reaching the patient but before causing harm (mitigated adverse drug event), or caught after some harm but before further or worsening harm (ameliorated adverse drug event). Pairs of physician and pharmacist reviewers confirmed recovered medication errors and assessed their potential for harm. Observers were unblinded and clinical outcomes were not evaluated.

Results
We conducted 226 observation sessions spanning 787 hours and observed pharmacists reviewing 17,320 medications ordered or administered to 6,471 patients. We identified 504 recovered medication errors, or 7.8 per 100 patients and 2.9 per 100 medications. Most of the recovered medication errors were intercepted potential adverse drug events (90.3%), with fewer mitigated adverse drug events (3.9%) and ameliorated adverse drug events (0.2%). The potential severities of the recovered errors were most often serious (47.8%) or significant (36.2%). The most common medication classes associated with recovered medication errors were antimicrobial agents (32.1%), central nervous system agents (16.2%), and anticoagulant and thrombolytic agents (14.1%). The most common error types were dosing errors, drug omission, and wrong frequency errors.

Conclusion
ED pharmacists can identify and prevent potentially harmful medication errors. Controlled trials are necessary to determine the net costs and benefits of ED pharmacist staffing on safety, quality, and costs, especially important considerations for smaller EDs and pharmacy departments.


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Medication Errors Recovered by Emergency Department Pharmacists