We should not look back unless it is to derive useful lessons from past errors, and for the purpose of profiting by dearly bought experience.
Ladies and gentlemen, did you know that 27% of prescribing errors that occur in the hospital result from incomplete medication histories at admission? 22% of discrepancies could have resulted in patient harm during their hospitalization. 59% of discrepancies could have resulted in patient harm after discharge, if the discrepancy had continued as ordered.
This stuff is no joke, folks.
IHI advocates medicine reconciliation at all transition points: at admitting, during transfer to other unit, and at discharge. More complex cases deserve a post-discharge phone call, or two, (or more). Consider creating a web portal for continuous communication, utilize smartphone apps, or try the following tips.
Printed Reference Sheets
A properly written, professional looking description of all new medications (provided by your pharmacy) must be handed out. This is an opportunity to treat your pharmacist like a valuable resource; have them teach you about a new medication. Support all verbal education about medications with take-home information sheets, printed from the nurse’s station.
Nurse preceptors can also role-play the education of patients: it gives new staff the confidence to have these critical conversations. You can tell somebody how important this is, but you won’t really know that they’ve mastered it unless you take five minutes and role-play.
Pharmacist rounding is absolutely critical to an overall vision of enhanced safety. With more sophisticated medications, or for help educating patients taking multiple medications (or patients who have complex medical issues), it is ideal to have a pharmacist come to the unit and answer patient questions.
The Take Away
Pharmacists are not just pill-counters; they’re valuable consultants for patients and healthcare professionals. Remember that medication errors are the leading cause of medical mistakes in the United States, and penalties for readmitting patients are going to become oppressive. Technology is an important resource, but not as important as staff skills and behaviors.
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