Wednesday, April 8, 2009

Fishing in a well-stocked pond

Florence has a sister, a new blog on the Medscape site called, "On Your Meds: Straight Talk about Medication Safety." I hope you'll take a look, and bookmark the site because On Your Meds is going to host a running commentary on specific strategies for reducing medication errors.

The current post is about high-alert medications, those with a heightened risk for causing harm if used in error. Insulin, chemotherapy, narcotics, drugs with weird dosing schedules, drugs with impossibly narrow therapeutic indices, drugs that result in closure of life-sustaining orifices if halted by mistake..... Let's just say that the drugs on ISMP's High-Alert list have earned their place.

I spent a year studying medication error prevention with ISMP, the nation's foremost experts on the subject. So I know more than the average bird, and often more than I wish I did, about medication errors. But you probably do, too: A medication error is 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.

People often wonder where I get the stories I use to illustrate key facts about med safety. Med errors can arise anywhere in the medication use process, a complex system (run by human beings) that includes: prescribing; dispensing; administering; and monitoring the effects of drugs.

Now consider that in a given week, an average of 82% of adults in the U.S. are taking at least one medication (prescription or nonprescription drug, vitamin/mineral, herbal/natural supplement); 29% are taking five or more. (These stats provide a snapshot of adults in community settings and exclude medications administered to people in hospitals and extended care facilities.) At this point, the stories find me. Or as Larry the Cable Guy might say, "You're fishin' in a well-stocked pond, sister."

Last week, I'm in the locker room at the YMCA, sharing a little more personal space than I'd rather. I've just finished cycling, and it looks like the Y member closest to me is preparing for "Twinges," the water class for people with joint disorders. She's chatting with a friend, and putting her clothes in a locker. The next thing I know, a bunch of pills, maybe 12, have spewed from the pocket of her balled-up Khaki pants. Some hit the bench, some the floor, and a few land in my gym bag. I help her retrieve them, phrases like "drug storage" and "mindfulness" flashing in my brain. She scoops up the last visible ones, examines her catch, re-pockets them, and says to her friend, "Good, I got the yellow one. We can still go to lunch."

I'm working on a project about insulin pens, visiting the manufacturers' Internet homepages and checking out the patient education materials available there. I notice images on a manufacturer's site where hip-looking teens are depicted using their insulin pens as hair accessories. Phrases like "drug storage" and "mindfulness" flash in my brain.

ISMP shares an error analysis in which a patient being treated for angina in a busy Emergency Department receives IV saline instead of IV nitroglycerin. The commonly used nitroglycerin is seated next to a similarly-appearing, but obsolete, glass bottle of 0.9% sodium chloride. The key elements? "Drug storage" and "mindfulness."

Across the continuum, themes repeat. I'll be reflecting more about them here at Florence dot com and at On Your Meds. In the meantime, it may be worth thinking about the utility of high-level risk-reduction tools. Should professionals use the same strategies to manage medication risks that senior citizens at the YMCA do?

No comments:

Creative Commons License
Florence dot com by Barbara Olson is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.