Medication Use Process

Medications are prescribed, distributed, and consumed under the assumption that the therapeutic plan will work as intended to provide the expected outcome. It is clear from previous chapters that there are many biological system issues that will influence success of the plan. Other organizational and societal system issues also influence success of the therapeutic plan as profoundly as do the biological systems issues. A prescriber writes an order for a medication based on the best available information, the likely diagnosis, and the expected outcome. A pharmacist reviews the requested medication order (prescription), clarifies it based upon additional information about the patient or medication (allergies, drug interactions, etc.), prepares the medication for use, counsels the patient about the drug, and gives it to the patient. The patient is responsible for understanding the therapeutic objective, knowing about the drug, creating a daily compliance plan (deciding when to take the drug), watching for good or bad results, and providing feedback to the prescriber or pharmacist regarding planned or unplanned outcomes. This process occurs over a variable period of time, in a system where the key participants of the process seldom speak with each other. Each action creates an opportunity for success or failure. Is there any wonder that the quality and integrity of the system are compromised on a regular basis?

The medication use system in an institutional setting offers even more complexity, with more chances for error. The five subsystems of the medication system in a hospital are selection and procurement of drugs, drug prescribing, preparation and dispensing, drug administration, and monitoring for medication or related effects (11). Evaluation and improvement of medication use quality require consideration of all of these subsystems.

Figure 26.2 is a flowchart of appropriate, safe, effective, and efficient use of medications in the hospital setting (12). It incorporates the role of the prescriber, nurse, pharmacist, and patient in a typical inpatient environment. It also depicts the role of the organization's pharmacy and therapeutics committee and quality improvement functions, which will be discussed later in this chapter. The decision to treat a patient in a hospital or extended-care facility typically adds a nurse or other healthcare provider (respiratory therapist, etc.) to the trio described in the ambulatory care setting. Every time that individual has to read, interpret, decide, or act is yet another opportunity for a mistake to occur. Each of the steps in the medication use process provides an opportunity for correct or incorrect interpretation and implementation of the tactics that support the therapeutic plan. With this many opportunities for medication misadventures to occur, it is easy to understand why tracking and improving quality are important aspects of medication use.

Phillips and colleagues (13) found a 236% increase in medication error-related deaths for hospitalized patients between 1983 and 1993. The same study showed an increase of over 800% for outpatient medication error deaths. The reported growth in medication error deaths may be partially attributed to more accurate reporting, but clearly represents a growth in the problem of medication errors from potent drugs. A 2002 poll commissioned by the American Society of Health-System Pharmacists concluded that the top two concerns of patients regarding hospitalization were related to drug-drug interactions and medication errors (14). A study by Bates et al. (15) determined that the 56% of medication errors in a hospital setting were associated with the ordering process, 6% with transcription of written orders, 4% with pharmacy dispensing, and 34% with administration of medications. Another study by Barker et al. (16) of medication administration in 36 healthcare settings identified a 19% total error rate during medication administration. Based on these findings it is easily concluded that there

Adverse

Drug

Events

FIGURE 26.1 Diagram showing the relationship between medication errors and adverse drug events. Because some adverse drug events are preventable, they are also considered to be medication errors (shaded area). (Adapted from Bates DW et al. J Gen Intern Med 1995;10:199-205.)

Dispensing Drug Process Diagram
Report reviewed by quality assurance and risk management
Medication Use Process

FIGURE 26.2 Flowchart of the inpatient medication use process, showing the start and end points (double-boxed rectangles), intervening actions (rectangles), and decision-making steps (ovals) required for appropriate, safe, effective, and efficient medication use. (Reproduced with permission from Atkinson AJ Jr, Nadzam DM, Schaff RL. Clin Pharmacol Ther 1991;50:125-8.)

FIGURE 26.2 Flowchart of the inpatient medication use process, showing the start and end points (double-boxed rectangles), intervening actions (rectangles), and decision-making steps (ovals) required for appropriate, safe, effective, and efficient medication use. (Reproduced with permission from Atkinson AJ Jr, Nadzam DM, Schaff RL. Clin Pharmacol Ther 1991;50:125-8.)

is room for improvement in how medications are used in the inpatient and outpatient setting.

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