Medication Management

Summary

The average patient is subjected to more than one medication error each hospital day, with an annual cost of $3.5 billion, according the IOM. Medication errors can occur anytime, in any step of the delivery process. Understanding the types and causes of medication errors can help hospitals identify gaps in the medication management process and allow them to take actions to help make patients safer. Most medication errors are not caused by individual carelessness, but rather by faulty processes that lead people to make mistakes or fail to prevent the mistakes from occurring in the first place.

The Institute of Medicine [i] has several recommendations to prevent medication errors. The series of steps are:

  1. A paradigm shift in the patient-provider relationship—Patients need to understand their medications and take responsibility for monitoring them. Providers should educate, consult with and listen to patients.
  2. Using information technologies to reduce medication errors—Clinical decision support and e-prescribing show the most promise in reducing medication errors. In fact, the committee recommends that all prescribers and pharmacies use e-prescribing by 2010.
  3. Improve labeling and packaging of medications—The drug industry and federal agencies need to work together to improve drug nomenclature and information sheets.

Health information technology shows promise in reducing the number of medication errors. Providers cannot keep up with all the relevant information available on medications and point-of-care reference information technology means they don’t have to. Additionally, e-prescribing eliminates handwriting errors and can automatically check for allergies, interactions and overly high doses. Hospitals are making slow, but steady progress in adopting these technologies. According to the 2009 Most Wired Survey and Benchmarking Study, 26 percent of respondents have medications entered by physicians, up 7 percent from 2008.

In addition, studies have shown that organizations that have instituted medication reconciliation have benefited from a reduced number of medication errors. Reconciliation is a process of identifying the most accurate list of all medications a patient is taking and using this list to provide correct medications for patients anywhere within the health care system. Reconciliation involves comparing the patient’s current list of medications against the physician’s admission, transfer and/or discharge orders. [ii]

Linkages to IOM Six Aims

Safe—Reducing opportunities for medication errors.

Effective—The “five rights”: the right patient, the right drug, the right dose, the right route, and the right time.

Business Case

Medication errors are among the most common medical errors. An estimated 1.5 million preventable adverse drug events occur in the United States each year, including 380,000 to 450,000 among hospital patients. Although patient harm caused by medication errors is most often temporary in nature, in some cases the harm can be permanent or even fatal. Additional hospital treatment costs are estimated at $3.5 billion. [iii]

Approximately $220 billion is spent on prescription drugs in the United States each year, with more than $50 billion spent on chronic medications. Patient adherence with prescribed medication regimens is less than 50 percent. About 130 million Americans have a chronic condition representing at least 50 percent of all prescriptions. Better medication management can lead to potential medical benefits and reduced costs of emergency room, inpatient hospital admissions, and physician practice visits. [iv]

An understanding of the costs associated with medical errors may help leaders understand the importance of patient safety from a financial perspective, develop measures to evaluate the impact of patient safety initiatives, and efficiently allocate resources to address this important health concern.[v]

Health Care Reform/Regulatory/Policy Considerations

FDA and the Institute for Safe Medication Practices have launched a national education campaign to eliminate the use of ambiguous medical abbreviations that are frequently misinterpreted and lead to mistakes that result in patient harm.

Linkages to Performance Excellence

Reducing Process Variation —Through understanding the process, organizations are able to focus resources where they will have the greatest impact to mitigate risk.

Eliminating Defects —Relying on regimented processes for administration of medications through implementation of technology or redesigned workflow.

Case Studies

More Case Studies

Resources & Tools for Medication Management

[i] Preventing Medication Errors 
IOM (Institute of Medicine). 2006.Washington: National Academy Press.
(accessed June 10, 2009)

[ii] Getting Started Kit: Prevent Adverse Durg Events 
10,000 Lives Campaign
(accessed June 10, 2009)

[iii] Preventing Medication Errors 
IOM (Institute of Medicine). 2006.Washington: National Academy Press.
(accessed June 10, 2009)

[iv] A Guide for Health Care Payers to Improve the Medication Management Process 
eHealth Initiative, June 2006
(accessed June 1, 2009)

[v] WB Weeks.  The organizational costs of preventable medical errors. Jt Comm J Qual Improv. 2001 Oct;27(10):533-9.
(accessed June 9, 2009)