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Study: Patient Safety Law Associated With Fewer Medication Errors

Medication Lists Taken by Pharmacy Staff at Hospitals Avoid Patient Harm, Required by New California Law

When pharmacy staff develop an accurate medication list for high-risk patients being admitted to a hospital, medication errors—that could have led to substantial complications or even death—are significantly reduced, according to a new study led by Cedars-Sinai investigators.

These findings, published in the American Journal of Health-System Pharmacy, demonstrated the impact of a new California law requiring pharmacy staff at acute-care hospitals with more than 100 beds to take a medication profile for high-risk patients upon admission.Rita Shane, PharmD

The law is based on California Senate Bill (SB) 1254, which took effect on Jan. 1, 2019, and was co-written by Cedars-Sinai Vice President and Chief Pharmacy Officer Rita Shane, PharmD, who championed the legislation, gaining support for it from key stakeholders.

“The results of this research illustrate the important role hospital pharmacists and pharmacy technicians play in improving patient safety and quality of care,” said Shane, who is also a professor of Medicine at Cedars-Sinai and senior author of the study. “SB 1254 legislation is based on innovative medication safety practices we developed at Cedars-Sinai. I’m gratified that patients throughout California can benefit from this important work.” 

When a patient is admitted to a hospital, their electronic health record may contain outdated and/or inaccurate information about their current medications. The medical record may not reflect recent changes, such as medications that patients have Donna Leang, PharmDstarted or stopped on their own, or it may contain incorrect doses or frequencies. These medication omissions and inaccuracies can lead to unintentional harm. 

“Getting a complete picture of a patient’s current drugs is critical to their health and safety, as clinical decisions are made based on this information during their hospital stay and at discharge,” said clinical pharmacist Donna Leang, PharmD, Medication Safety officer at Cedars-Sinai and a study co-author.

Study investigators assessed the impact of the new California law by analyzing the errors caught by pharmacy staff and evaluating the potential harm avoided. They conducted their analysis at 11 hospitals in the state over six consecutive weeks between January 2020 and June 2020.

Participating hospitals captured medication history errors identified among high-risk patients, including older adults, individuals with chronic conditions or patients taking multiple drugs. Investigators sorted the errors by type, ranking the severity of potential or actual harm posed by the errors.Thanh Tu, PharmD

Approximately 94% (2,554) of medication histories contained at least one error, and approximately six errors were identified and avoided per patient. About 54% (1,474) of patients had at least one serious or potentially life-threatening error on their medication list, and 25% of all errors prevented by pharmacy staff were potentially serious or life-threatening.

Participating hospitals found more than 15,000 medication history errors during the six-week study period. The most common errors included leaving out medications, including therapies that are no longer being prescribed or taken, and listing incorrect doses, rates or frequencies for medications.

“If not intercepted, these errors could have resulted in adverse outcomes for some of the most vulnerable patients,” said study co-author Thanh Tu, PharmD, a clinical pharmacist and Pharmacy Program coordinator at Cedars-Sinai. “It is striking to see how having trained pharmacy professionals obtain accurate medication histories can have such a big impact on patient safety.”

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