North Carolina State Board Leads Way As Regards Reporting Of Pharmacy-Associated Medication Mistakes
(Posted by Tom Lamb at DrugInjuryWatch.com)
QJM is a long-established, leading general medical journal. It focuses on internal medicine and publishes peer-reviewed articles which promote medical science and practice.
In the August 2009 edition of QJM is an article, "Medication errors: what they are, how they happen, and how to avoid them", which provides a good overview of the various aspects of a medication mistake. Here are some fundamental points from the Abstract for this recent medical journal article:
- A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient.
- Medication errors can occur in
-- deciding which medicine and dosage regimen to use (prescribing faults—irrational, inappropriate, and ineffective prescribing, underprescribing, overprescribing); writing the prescription (prescription errors);
-- manufacturing the formulation (wrong strength, contaminants or adulterants, wrong or misleading packaging);
-- dispensing the formulation (wrong drug, wrong formulation, wrong label);
-- administering or taking the medicine (wrong dose, wrong route, wrong frequency, wrong duration);
-- monitoring therapy (failing to alter therapy when required, erroneous alteration).
[Note: Format of sentence was changed for easier reading.]
- [Medication errors] can be classified, using a psychological classification of errors, as knowledge-, rule-, action- and memory-based errors.
- Errors in prescribing include irrational, inappropriate, and ineffective prescribing, underprescribing and overprescribing (collectively called prescribing faults) and errors in writing the prescription (including illegibility).
Remarkable to me, at least, is that only one state, North Carolina, has a mandatory reporting requirement for medication errors that involve a pharmacist or pharmacy.
According to "What state boards are doing about medication errors", an online special article published July 1, 2009 by Drug Topics ("The Newsmagazine for Pharmacists"):
As of June 2009 it appears that North Carolina remains the only state that requires any consistent public reporting of pharmacy-associated medication errors. In North Carolina, pharmacists must report errors associated with deaths.
According to Jay Campbell, RPh, JD, executive director of the N.C. Board of Pharmacy in Chapel Hill, “The requirement is that one needs to report [an error] to the board of pharmacy if they have reason to believe that a dispensed drug caused or contributed to a death of a patient. It is not a mandatory reporting of serious errors, only a report of deaths. Some of the data [we gather] are made public, and some aren’t. We produce a spreadsheet of information and we scrub out certain things that are not public information,” he said.
Campbell explained to Drug Topics that the “reporting rule isn’t keyed to an error; it’s broader than that. [We require a report] even if a drug is dispensed as ordered, yet it contributed to a death. Sometimes there’s a need to investigate — especially in a hospital, where a patient may have come in with underlying problems. There does sometimes seem to be a temporal relationship.”
This Drug Topics article adds that the North Carolina state board receives on average 40 to 60 reports per year, and, according to Campbell:
In our experience, we have seen a disproportionate number of deaths with anticoagulant products. They are a tiny fraction of global dispensing, yet they have, over the years, represented about 20 percent of reports.
Previous Drug Injury Watch articles about this subject area can be found in the Medication Errors category archives.