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INFLUENCE OF INTEGRATION OF A PHARMACIST IN MEDICATION ERRORS IN CRITICALLY ILL PATIENTS

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European Statement

Patient Safety and Quality Assurance

Author(s)

A. Valladolid-Walsh, E. Domingo-Chiva, P. Cuesta-Montero, J.A. Monsalve-Naharro, E.M. García-Martínez, S. Plata-Paniagua, M.D. Pardo-Ibañez, G. Romero-Candel, J.M. Jiménez-Vizuete, R. Peyró-García

Why was it done?

To determine the incidence of medication errors in our environment and implement enhancement systems to prevent them, which is a priority for the improvement of the drug treatment process in critically ill patients.

What was done?

A clinical pharmacist was integrated on a full time basis into the multidisciplinary team of an anaesthesia intensive care unit (ICU).

How was it done?

The project was carried out in 3 different stages:

– First stage: a prospective observational study was carried out over 1 month to detect medication errors in anaesthesia ICU and to determine the baseline situation before the pharmacist´s intervention. During this stage, 36.27% errors were detected in overall treatments.

– Second stage (intervention stage): Over 10 months, the pharmacist reviewed the prescriptions of all patients admitted to the anaesthesia ICU, performing the appropriate interventions regarding medications. Furthermore, to educate physicians and nursing staff, we organised educational meetings, and also pharmacotherapeutic protocols and guidelines of medication administration were created to standarise clinical practice. Finally, a system for reporting medication errors was introduced.

– Third stage: a prospective observational study was carried out for 1 month to detect medication errors after the pharmacist’s intervention. During this stage, 5.9% of errors were detected in overall treatments.

What has been achieved?

– Medication errors were reduced by more than 30%.
– A pharmacist is now part of the multidisciplinary team in the ICU.
– The experience has been broadcast to the national level to promote the implementation of clinical pharmacist activities in our environment.

What next?

We are still working on the same areas to improve safety in drug therapy in critically ill patients. Currently, improvement measures that are being developed are: new pharmacotherapeutic protocols specifically for this unit; drugs and drug-diluent compatibility guidelines; new training sessions; standarised medication kits in operating rooms and implementation of the computerised prescription; and a new labelling system for syringes.

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