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Medication Errors Plummet when Pharmacists Take Medication Histories

By Alexandra Wilson Pecci  
   December 07, 2017

Findings from a new study prompted a change at Los Angeles-based Cedars-Sinai. 

A study that tasked pharmacy staff members—rather than doctors or nurses—with taking medication histories in the ED resulted a more than 80% drop in medication errors.

Those findings prompted a change at Los Angeles-based Cedars-Sinai: Now, pharmacy staffers take medication histories for certain high-risk patients who are admitted through the ED.

In the study, published in BMJ Quality & Safety, researchers focused on 306 medically complex patients at Cedars-Sinai who were taking 10 or more prescription drugs and had a history of heart failure or other serious conditions.

It found that when pharmacists or pharmacy technicians, instead of medical staff, took these patients' histories in the Cedars-Sinai ED, errors in both the histories and medication orders fell by more than 80%. As a result, significantly fewer drug-order errors were made during hospitalization.

"The standard practice in the U.S. is for doctors and nurses to take these histories, along with simultaneously delivering and coordinating care for the patients," Joshua Pevnick, MD, associate director of the Division of Informatics at Cedars-Sinai and the study's first author, said in a statement. "That's why it's so helpful to assign this task to pharmacy experts, whose sole role is to take these histories."

Getting accurate histories often requires reconciling several information sources, including EHRs, prescription databases, written lists, and information provided verbally. It can be even harder to get the correct medication histories of ED patients.

But being accurate right out of the gate can prevent errors down the road.

"Across healthcare settings, errors that are introduced into the record by individuals with varying levels of knowledge can become 'hardwired' and used for prescribing medications that can cause harm," Rita Shane, PharmD, chief pharmacy officer at Cedars-Sinai and a co-investigator for the study, said in a statement.

Cedars-Sinai now assigns pharmacy staff to take medication histories for certain high-risk patients admitted through the ED, including patients who are are elderly and reliant on multiple drugs. This also allows doctors and nurses to focus on patient-care needs, researchers said. 

Alexandra Wilson Pecci is an editor for HealthLeaders.

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