Risk Management _ __________________________________________________________________________
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
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]. When terminating a patient-physician relationship, the physi- cian should send a letter to the patient, notifying him or her that the relationship will be terminated by a specific date, typically 30 days from the date of the letter [165]. The letter should be sent by certified mail with a return receipt requested to ensure appropriate delivery. A copy of the letter and the return receipt should be kept in the patient’s medical record. Physicians should not refill a patient’s prescription beyond the date of termination [9; 165]. Physicians are not obligated to help patients find another physician, but assisting with the transfer of medical records demonstrates an interest in facilitat- ing continuity of care, which may be helpful in the event of litigation [165]. The AMA Code of Ethics includes guidance on terminating the patient-physician relationship [166].
have now been replaced by e-prescribing issues, such as select- ing 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 formula- tion (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 pro- gram 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.
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