medication errors in general medicine wards and need of pharmacist intervention

To err is human and a doctor is human. Patients will be safer when we accept this reality and design clinical tasks accordingly. This is to understand circumstances that can entail unforced errors either by the attending clinician or the support staff. Medication errors pervade all phases of acute care. About 20% of patients will have a potentially harmful error in their preadmission medication history that may result in an incorrect medication order at the time of admission. (1) Drug therapy enhances health related quality of life (QoL) for most of the diseases1. Despite excellent benefits and safety profile of most medications, Medication errors pose a significant risk to patients, which adversely affect quality of life (QoL), increases hospitalization and overall healthcare costs2,3. However, optimization of drug therapy may, by preventing MEs, influence health expenses, potentially save lives and enhance patient’s quality of life1, 2, 3 In the past decade, medication errors have become to be recognized as an important cause of iatrogenic disease in hospitalized patients although not all result in actual harm. Medication prescribing deficiencies are the most common cause of actual and potential adverse events4. Increased use of medication and availability of new drug therapies potentially increase the risks of patient for iatrogenic adverse drug events in hospitals4,5. Iatrogenic adverse events are important for consideration because it can not only prolong hospital stay but also increase the patient healthcare expenditure. Therefore, it is important that all drug related problems resulting in serious injury or death are evaluated to assess whether improvement in the healthcare delivery system can be made to reduce the likelihood of similar events occurring in the future 4,5. The National Coordinating Council for Medication Error (NCCMER) defines a medication error as being ‘‘any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient or consumer.’’ Such events may be related to professional practice, health care products, procedures and systems including: prescribing; order communication; product labelling, packaging and nomenclature; compounding; dispensing; distribution; administration; education monitoring; and use.(3) Common causes of medication errors include incorrect diagnosis, prescribing errors, drug-drug related reactions, dose miscalculations, incorrect drug administration and lack of patient education. Other factors that can contribute are job-related stress; improper training or education and sound-alike lookalike packaging of medications. Medication errors directly impact the lives of the patients. It also leaves a lasting negative impression on the minds of the people about the hospital Drug therapy is growing more complex1,2, thus making appropriate drug prescribing increasingly challenging. In a survey conducted by Von Gunten et al, have shown that 22-65% of antibiotics prescriptions are either inappropriate or incorrect (6). Inappropriate use of drugs may be harmful and could evoke new symptoms. In clinical medicine, a wide range of Medication errors (MEs) might arise due to various causes3, 7. Of the various factors encountered in medical practice lead to MEs or medical prescribing errors, improper dosage, improper drug selection, drug-drug interaction, drug without indication, untreated indication are the most common7. The cause of MEs also includes those that are iatrogenic and idiosyncratic in nature. In addition, factors like increased use of medications, polypharmacy, and availability of new drug therapies will potentially increase the risk of drug-induced illness3, 7. Medication errors that lead to iatrogenic injuries are a well-known worldwide phenomenon and are common, costly and clinically important. In 1910, Richard Clark published the first study that looked at error rates in clinical diagnosis. Since then, several studies have looked at the problem of medication errors. Medication errors are a common occurrence and continue to be a problem in the health care industry. It is estimated that the annual cost of drug-related morbidity and mortality is nearly $ 177 billion in the United States. Approximately 7,000 deaths occur each year and medication errors occur in just about 1 of every 5 doses given in hospitals. There is at least one death per day and 1.3 million people are injured each year due to medication errors. (1) How does the quality and availability of healthcare services keep pace with a vastly improving standard of living in a rapidly developing country? And to what extent can access to that quality care be available to all socioeconomic levels? These questions have a special relevance to India because progress in healthcare availability – or the lack of it – will accelerate or deter growth. Studies on the prevalence of MEs in hospitals and a closer characterization of all MEs are virtually lacking and the bedside clinical approach evaluation of patients’ MEs has rarely been applied1. However, in few countries several studies and precautions have been carried out to assess and minimize MEs in hospitals7. In one study, it is reported that drugs are the most common cause of medication errors in hospitals, affecting 3.7 % of patients. However, hospital medication error occurs in 3-6.9 % of in-patients and the error rate for in-patients’ medication orders was reported to be 0.03-16.9 % with each hospital experienced a medication error every 22.7 hours8. In a study conducted in India, it is reported that the incidence of MEs was found to be greater than quoted as an average in developed countries. The study also reported that the high incidence of inappropriate dosage and improper drug selection may be due to the lack of standard treatment protocols or a formulary for hospital and the differing treatment patterns between the medical wards in each Indian hospital3 Undoubtedly, MEs has to be controlled or prevented to provide better patient care. However, drug therapy has become so difficult that no one professional is expected to optimize the drug therapy and control MEs alone8. Today there exist a due problem in medical care that urgently requires expert attention namely that of preventable drug related morbidity and mortality3, 9. These problems could be well preventable / minimized by initiating changes in drug therapy through clinical pharmacy services3 Clinical pharmacy services are those services provided by pharmacist in an attempt to promote rational drug therapy that is safe, appropriate and cost effective. Clinical pharmacist visits wards regularly to monitor for completeness and accuracy of prescriptions, is available for consultation by medical and nursing staff and ensures that the drug distribution system is operating correctly10. Clinical pharmacist by providing various clinical pharmacy services can improve patient care and decrease healthcare cost by his / her intervention to optimize medication use, avoid or mitigate drug related problems such as adverse drug reactions and drug–drug interactions, ensure the rational use of medications, and improve patient compliance with medications11. Pharmacists in hospitals frequently initiate changes to patients’ drug therapy and management to promote rational drug use. Several studies had shown that there is possible reduction in drug related problems through pharmacist-initiated changes in drug therapy2, 12. Consol Galindo et al reported that pharmacist interventions have been important to help educate physicians and have been useful to improve quality of drug therapy and patient care13 Drug spending shows no signs of slowing, and in future, Medicare beneficiaries are expected to incur an average of $3,160 in annual drug expenditures14. A study in the United States estimated that the cost of treating conditions caused by inappropriate medication was US $177.4 billion in 20008. It is reported that high expenditure towards medical expense patients skip the medication or no adherence to the medication that will enhances the disease condition. However, numerous studies reported that the provision of clinical pharmacist services could result in cost savings, cost avoidance; decrease hospital stay and improves better patient care12. In United States, decreased hospital mortality rates and reduced healthcare costs have also linked the presence of clinical pharmacy services in hospitals8. Pharmacist’ can ensure appropriate drug use, decrease out of pocket expenditures, and improves access to needed drugs14 by providing consultation at the point of care. In a recent study it is reported that the annualized cost savings relating to length of stay, readmission, drugs, medical procedures and laboratory monitoring as a result of clinical pharmacist initiated changes to hospitalized patient management or therapy was $ 4444794 for eight major acute care government funded teaching hospitals in Australia2. When a pharmacist initiated changes to drug therapy it will not only have a positive economic effect on the health care system but ultimately also will have the potential to save thousands of lives8, 15. Although numerous studies detail how medication errors come about, the extent to which they occur, their associated costs, the various roles played by healthcare practitioners, the impact of pharmacist-initiated interventions has not been evaluated and quantified outside particular specialized areas of service provision. Also, studies on the projected cost savings of clinical pharmacy services provided to hospitalized patients in major acute care teaching hospital are limited. Moreover, in Indian setup, the studies assessing the pharmacist interventions and it’s cost saving has not been well demonstrated. The Government of India addresses health policies, regulatory matters and disease control. The states address healthcare delivery, financing, and the training of personnel. The national Ministry of Health has several functional departments: Health Services, Family Welfare, Health Research, and Traditional Medical Systems. The state ministries typically have departments of Medical Education and, similar to the national ministry, Health Services and Family Welfare.5 Despite this large infrastructure and attention to need, the public sector actually provides only about 20% of actual care services. The balance of care is provided by private hospitals and practitioners. India faces enormous challenges as it builds its healthcare system to meet the rapidly growing needs and desires of a burgeoning middle-class that will increasingly want, expect, and ultimately demand, world-class healthcare. Great challenges bring great opportunities. Enterprising companies, individuals and government entities are rising to the challenge and doing wonderful things in India’s healthcare sector. Nearly 80% of outpatient healthcare and more than 50% of hospital care in India is provided by the private sector. For patients, this is generally an out- of-pocket expense, to an extent where many have had to sell assets and take loans to finance hospitalisations. Besides cost, an additional problem is that outpatient services are mainly provided by fragmented and unregulated healthcare providers, many of them in the informal sector with limited or no formal training in healthcare. India would have one of the highest numbers of healthcare workers per capita in the world, if the informal providers are taken into account. However, the quality of health services is a major concern, with over-prescription of antibiotics, use of steroids and delayed referrals, being serious issues that are commonly encountered. A clinical role for pharmacists has developed in response to the societal need to improve the use of medicines. The increasing complexity in the management of drug therapy has given pharmacists clear roles that integrate within the healthcare team. Clinical pharmacists are uniquely trained in therapeutics and provide comprehensive drug management to patients and providers (includes physicians and additional members of the care team). Pharmacist intervention outcomes include economics, health-related quality of life, patient satisfaction, medication appropriateness, adverse drug events (ADEs), and adverse drug reactions (ADRs). Providing high-quality, safe medical care is the primary goal of health systems. Pharmacists are well positioned to assist the healthcare system in improving quality of care. The term pharmaceutical care was coined by the Heppler and Strand who defined the term as responsible provision of drug therapy for the purpose of achieving definite outcomes which improves the patient quality of life. It was suggesting that the pharmaceutical care involves the process in which a pharmacist co-operates with a patient and health care professionals in designing, implementing and monitoring a therapeutic plan which will produce specific outcome1. Pharmaceutical care was embraced by UK pharmacists and the Royal pharmaceutical society. It was incorporated into professional guidelines of good practice with little debate as to its appropriateness to UK practice. The use of the more traditional term of clinical pharmacy was superseded rapidly by pharmaceutical care as a description of the work of a ward based hospital pharmacist, but the practice itself did not change radically2. Pharmaceutical care is a generalist practice which has evolved from many years of research that can be applied in all settings: community; hospital, long-term care, and the clinic. It can be used to care for all types of patients with all types of diseases taking any type of drug therapy. Pharmaceutical Care practitioner is not intended to replace the physician, the dispensing pharmacist, nurse or any other health care practitioner. Rather, the pharmacy practitioner is a new patient care provider within the health care system1. Hence this study is intended to assess the pharmacist-initiated changes to drug therapy and its cost saving in JSS tertiary care teaching hospital, Mysore.