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Hospital Medication Errors Being Tackled

Hospital Medication Errors Being Tackled In Variety Of Ways

Medication errors are under the spotlight in public hospitals throughout New Zealand, with a range of solutions being introduced or trialled. Some of this work will be discussed at a national conference on The Safe Use of Medicines in Wellington on 6th and 7th May.

International research pinpoints medication errors as one of the most preventable adverse incidents.

In recent years, New Zealand’s public hospitals have put considerable effort into reducing the level of drug related adverse incidents, both actual and potential.

Strategies range from the installation of highly sophisticated new equipment down to instituting and mandating standard systems, processes and protocols.

“Busy hospitals under pressure rely on their pharmacists to pick up prescribing errors. We need to develop ‘whole system’ approaches”, says the Chair of the Safe Use of Medicines Group Dr Dwayne Crombie. “Prescribing is a significant area where mistakes occur and so is the actual administration of the drug, while it’s much less usual to have dispensing errors they do happen.”

Since chairing this group, Dr Crombie has been heartened to learn of some of the innovative work being done around the country by DHBs. “Some of the

changes are really quite simple and basic such as involving pharmacists on ward rounds, others are more complex and need support internationally such as bar coding of drugs. Work also includes the introduction of new technologies such as electronic prescribing and automated dispensing on the wards and the work in progress on new electronic programmes to link prescribing, dispensing and administration of drugs.”


The start of electronic prescribing on wards, which improves legibility and point of care information, allows availability of medication charts with accurate and up to date record for all members of healthcare team regardless of where patient is.

Electronic recording of medicine administration and online review of medication charts by pharmacists being developed.

IDAS - a drug recognition system using bar coding in theatres that feeds back continuous information to anaesthetists about the drugs and quantities of drugs being used during an operation. As a result of this work The Food & Drug Agency in the USA is likely to introduce a bar coding system for the identification of drugs.

Automated dispensing systems on wards, Pyxis now in use in 3 NZ Hospitals.

Consideration being given to patient bedside lockers with secure medication drawers.

New pharmacy information systems. Systems to provide dispensing checks and links to electronic prescribing and recording of medicine administration have been partially introduced or are in development. Pharmacy Intervention database capturing complete information on all interventions by clinical pharmacists

Smart Infusion Technology being trialled – Infusion pumps on which pharmacists can set maximum and minimum i.v. dosage limits to prevent over or under dosages being administered.

Consistent protocols for high risk drugs, eg using one brand and one pill strength of the drug Warfarin.

Pharmacy involvement with patients on high risk drugs such as Warfarin, auditing of patients admitted with high INR levels and feedback loops and education of community pharmacists, practice nurses and GP on its use. Zero tolerance policies on aspects of prescribing – eg allergy boxes must be completed by prescriber before pharmacy dispenses a prescription, no overwriting of prescriptions.

Common drug charts throughout a hospital.

Standardisation of drug protocols throughout a hospital, replacing unit specific ones.

Use of MIMS electronic database (user friendly drug information programme) capable of being uploaded onto palm tops and on Intranet on wards and hand held PCs, providing accessible up to date information to all clinical staff

e-formulary on Intranet.

Electronic patient information leaflets available on wards for nurses to give patients.

Clinical pharmacist involved in multidisciplinary team focussing on individual patients, involved in medication history, assessment, reviewing of medication orders, adverse drug reaction monitoring, clinical review, selection of medicine therapy, participation in wards rounds and meetings, patient education about their medicines and community liaison.

Medicine Administration Testing for nurses – new competency tests structured to test actual knowledge of administration processes as well as theoretical understanding of policies – similar in concept to competency tests undertaken in aviation industry.

The Safe Use of Medicines Conference is being sponsored by DHBNZ; Pharmac; The Ministry of Health; The Australasian Society of Clinical and Experimental Pharmacologists (ASCEPT) and PreMec.

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