___________________________________________________________________________ Risk Management
[65; 162]. Inadequate monitoring has caused a wide variety of adverse effects, such as electrolyte/renal imbalance, bleeding, gastrointestinal toxicity, and neuropsychiatric events, and often requires hospitalization of the patient [65; 161]. Other common medication-related errors are a failure to prescribe prophylactic agents when appropriate (as for patients taking nonsteroidal anti-inflammatory agents or anticoagulants) and drug-drug interactions [58; 161]. Studies and reviews of malpractice claims have identified several drug classes that are most often associated with preventable medication errors: antibiotics, antidepressants or antipsychotic agents, cardiovascular drugs, anticoagulants, analgesics, hypoglycemic agents, and diuretics [64; 65; 161]. As with most medical errors, preventable medication errors are most frequently caused by system deficiencies [64]. Electronic prescribing systems have not been found to reduce the number of prescribing errors; for example, handwriting legibility issues have now been replaced by e-prescribing issues, such as selecting the wrong box in a dropdown menu [162; 163]. General medication errors are still common. A 2014 observational study found that the most frequent prescribing errors were wrong drug quantity (40%), wrong duration of therapy (21%), wrong dosing directions (19%), and wrong dosage formulation (11%) [163]. Several strategies can help physicians avoid medication errors ( Table 7 ) [9; 164]. QUALITY ASSURANCE PROGRAM Risk management should also involve a quality assurance program in which the efficiency and outcomes related to policies and procedures are evaluated on an ongoing basis. All staff should be encouraged to provide feedback on ways to improve care; patient complaints can also provide
opportunities for improvements [9]. In addition, physicians should evaluate their practice behaviors to identify evidence of defensive medicine to help eliminate variations in care and promote better patient outcomes. It is also important to create an environment in which patient safety is emphasized. Physicians should provide leadership within the practice, encouraging teamwork, offering feedback on performance, and providing access to necessary training and continuing education for all staff [9]. OTHER ISSUES Other issues that should be addressed in a risk management program are the scope of practice, termination of the patient- physician relationship, and retention of medical records. Scope of Practice All staff should perform only those tasks that are within the scope of their job descriptions, licensure, or certification [9]. In addition, staff should operate or maintain medical equipment or devices only if they have received appropriate training and have been certified (if required). Termination of Relationship Physicians should have a standardized procedure for dismissing patients (i.e., terminating the patient-physician relationship when the patient presents insurmountable problems, such as unresolved issues with missed appointments, abusive treatment of staff, or threatening behavior) [165]. It is recommended that a physician dismiss a patient who has filed a malpractice suit [71; 165].
STRATEGIES FOR AVOIDING MEDICATION ERRORS Perform a thorough examination before prescribing medication or renewing a prescription (especially opioids). Review medication list with the patient (including all over-the-counter medications, dietary supplements, herbal remedies, vitamins, etc.) at each visit and during transitions of care (e.g., hospital to outpatient). Give a written medication list to the patient; the list should include the name of the drug, its purpose, the dosage, the directions for use, and side effects. Discuss how and when the patient should take the medication. Review the side effects of a new medication, as well as potential drug-drug or drug-food interactions, and tell the patient what to do if side effects or interactions occur. Review the role of the medication in the overall context of the patient’s health. Establish guidelines to manage prescription calls and refills and record the calls with the date and time in the patient’s chart. Inform the pharmacist about the patient’s comorbidities, allergies, and weight when calling in a prescription. If providing medication samples, record the lot number in the patient’s record (in case of a recall of the medication). When administering a medication: • Double check the vial or bottle label against the order. • Ask the patient if he or she has an allergy to the medication, even if no drug allergies are noted in the medical record.
Source: [9; 164]
Table 7
39
MDMI1826
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