Medication Safety in the Primary Care Physicians Office

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Medication Safety in the Primary Care Physicians
Office
Kim Galt Ann Rule Bart Clark JD Bramble
Wendy Taylor and Kevin Moores
Creighton University Health Services Research
Program
AcademyHealth Annual Research Meeting San Diego,
CA June 2004
Support - Agency for Healthcare Research and
Quality, Galt, K.A. 1-R18HS11808-01
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AHRQ Study No. R18-HS11808-01 Impact of personal
digital assistants (PDAs) on medication errors in
primary care
Potential Prescribing Errors Office
technology assessment User technology
assessment Drug Information assessment
Year 1 Baseline Data
RCT 40,000 Rxs/ Cht Reviews Error Measurement

• Individual User Adaptation to PDA
• Individual User Adoption of PDA
• Barriers and solutions to
• PDA adaptation/adoption

Year 2 Intervention Data
Direct observations Field journal notes Written
surveys
Potential Prescribing Errors Office
technology assessment User technology
assessment Drug Information assessment
Direct observation Performance
checklists Self-report surveys Field observations
Year 3 Post-Intervention Data
RCT 40,000 Rxs/ Cht Reviews Error Measurement
Interviews Field observations
1. Galt, KA, et al. Impact of hand-held
technologies on medication errors in primary
care. Top Health Inform Manage, 2002, 23(2),
71-81. 2. Galt, KA. Medication errors in
ambulatory care. Top Health Inform Mange, 2002,
23(2), 34-46.
Direct observations Field journal notes Written
surveys
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The Electronic Medical Record?...
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The data jack
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Supposed to be a data jack...
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Data jack strategically placed over examination
table
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The Intervention
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Rationale

• Medication safety is missing as a governing
  concept in primary care office-based practice.

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Purpose

• Assess medication safety in primary care practice
  through survey research and direct observation
• Use evidence to identify areas of emphasis for
  medication safety best practices
• Develop a medication safety best practices guide
  for office use

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Domains for Medication Safety
Domains
Subdomains
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Figure 1 Medication Use Process and Care
Communications in the Outpatient Setting
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Methods

• Develop a 154 item medication safety assessment
  survey
• Administer survey (interviewer-assisted) to 31
  primary care office managers in Nebraska and Iowa
  in May, 2003
• Directly observe offices to assess environment,
  facilities, technology readiness, and office
  behaviors related to medication safety.

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Results Update Patient Record When Change
Medication Care Plan

• 71 of offices surveyed report that they do not
  update the chart when renewing medications by
  telephone.

Med Profile Updated
Med Profile Not Updated
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Why do only 29 of offices update the chart
after renewing a medication by phone?
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Results Prescriptions
When telephone orders are given, only 36 report
that the pharmacist always or almost always
repeats the prescription back for verification.
The Individual telephoning a prescription informs
the pharmacist of the following Only 32 of
clinics report informing the pharmacist of the
indication, a practice that has been shown to
reduce errors.
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Results Sample Medications
56 - no established procedure for providing
prescription medication samples to patients.
Only 6 of clinics label samples for patients to
use in the home to assure proper use.
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Why do only 6 of offices label the sample for
the patient before giving it to them to take home?
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Early attempt at medication safety system
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Efficient use of FTEs Pharmaceutical Representa
tives are part of the primary care workforce too!
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Results

• Error Management
• 33 - no outlined procedure to respond to a
  serious medication error
• 88 - reporting mechanism in place
• Work Place Conditions
• 24 - dismissed individuals from employment
  because of error
• 65 - reference errors in personnel files
• 71 - part of performance appraisal

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Results Areas for Improvement

• Data gathering and chart documentation
• basic patient health information and current
  medication history each change in care plan
• Change what is included on a prescription
• Indication
• Date of birth, weight, allergies
• High-risk co-morbid conditions

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Results Areas for Improvement

• Incorporate safe sample management consistent
  with pharmacy practice standards
• Use errors events to educate and improve process,
  not punish individuals
• Educate routine staff about strategies designed
  to reduce errors
• Incorporate no cost strategies to prevent/reduce
  errors

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Medication Safety Best Practices Guideline
Development

• Survey items converted if met explicit criteria
• Direct relevance to medication safety
• Increased risk if not attended to
• Feasible to implement solution
• Practices identified into 3 implementation
  categories
• Solution is individual behavior, no added
  resources
• Solution is in policy/system, no added resources
• Solution requires additional resources

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Conclusion
Medication safety practices in the primary care
office are suboptimal to unacceptable Improving
the medication use process in primary care
offices is a critical step to improving
medication safety for the public. Many solutions
at no to low cost. A best practices guideline
may assist office practices with these
improvements.