Medication Safety in the
Primary Care Physician’s
Office
Kim Galt; Ann Rule; Bart Clark; JD Bramble;
Wendy Taylor; and Kevin Moores
Creighton University Health Services Research Program
AcademyHealth Annual Research Meeting
San Diego, CA June 2004
Support - Agency for Healthcare Research and Quality, Galt, K.A. 1-R18HS11808-01
AHRQ Study No. R18-HS11808-01
Impact of personal digital assistants (PDAs) on
medication errors in primary care
Year 1 Baseline Data
Potential Prescribing Errors
RCT: 40,000 Rx’s/ Cht Reviews Error Measurement
Office technology assessment
User technology assessment
Drug
Information assessment
Direct observations
Field journal notes
Written surveys
Year 2 Intervention Data
Individual User Adaptation to PDA
Individual User Adoption of PDA
Direct observation
Performance checklists
Self-report surveys
Field observations
Year 3 Post-Intervention Data
Barriers and solutions to Potential Prescribing Errors
PDA adaptation/adoption RCT: 40,000 Rx’s/ Cht Reviews Error Measurement
Interviews
Field observations
1. Galt, KA, et al. Impact of hand-held technologies on medication
errors in primary care. Top Health Inform Manage, 2002, 23(2), 71-81.
2. Galt, KA. Medication errors in ambulatory care. Top Health
Inform Mange, 2002, 23(2), 34-46.
Office technology assessment
User technology assessment
Drug Information assessment
Direct observations
Field journal notes
Written surveys
The Electronic Medical Record?...
The data jack
Supposed to
be a data jack...
Data jack strategically placed
over examination table…
The Intervention…
2
3
1
4
Rationale

Medication safety is missing as a governing
concept in primary care office-based practice.
Purpose



Assess medication safety in primary care
practice through survey research and
direct observation
Use evidence to identify areas of
emphasis for medication safety best
practices
Develop a medication safety best
practices guide for office use
Domains for Medication Safety
Domains
Subdomains
Medication Use Process
11
Patient Interactions and Medication Safety
2
Office Environment
6
Error Management
3
Workplace Conditions and Safety Perceptions 4
Safety Education
3
Technology and Medication Safety
4
Figure 1: Medication Use Process and Care Communications in the Outpatient Setting
Patient
Renewal
or
Refill
Physician’s Office
Prescribing
- Evaluate patient
- Establish need for medication
- Determine interactions and allergies
- Consider financial situation
- Consider formulary or insurance issues - Select correct medication
New
or
Renewal
Counseling
- Counsel patient about medication1
- Answer medication related questions
- Give written information
- Give telephone number for medication information
Documenting
- Document in patient’s chart
Pharmacy3
Transmission
-Transmit prescription to pharmacy
- Write prescription & patient takes to pharmacy
- Call pharmacy with prescription order
- Fax prescription order to pharmacy
Issuing Sample Medications (MD office)
- Review prescription order
- Prepare sample medications
Administering (in-office use medication)
- Evaluate patient
- Review warnings, interactions and allergies
Monitoring2
- Assess patient’s response to medication
Clinical Evaluation (Pharmacist)
- Review prescription order
- Review directions, reason for use, warnings, interactions and allergies
- Contact prescriber about discrepancies if necessary
- Counsel patient1
- Distribute sample medications
- Review prescription order
- Administer medication
- Report and document results
Dispensing
- Prepare medication
- Give medication to patient
Counseling
- Counsel patient about medication1
- Answer medication related questions
- Give written information
- Give telephone number for medication information
Monitoring2
- Assess patient’s response to medication
- Report results
Methods

Develop a 154 item medication safety assessment
survey

Administer survey (interviewer-assisted) to 31
primary care office managers in Nebraska and Iowa
in May, 2003

Directly observe offices to assess environment,
facilities, technology readiness, and office behaviors
related to medication safety.
Results: Update Patient Record
When Change Medication Care Plan

71% of offices surveyed
report that they do not
update the chart when
renewing medications by
telephone.
29%
Med
Profile
Updated
Med Profile
Not Updated
71%
Why do only 29% of offices update the chart
after renewing a medication by phone?
Results: Prescriptions
When telephone orders are
given, only 36% report that the
pharmacist always or almost
always repeats the
prescription back for
verification.
10%
13%
The Individual telephoning a prescription
informs the pharmacist of the following:
Only 32% of clinics report informing
the pharmacist of the indication, a
practice that has been shown to reduce
errors.
100
DOB
Seldom Always
87%
90
80
70
Almost
Always
Sometimes
23%
60
Indications
for
Use
Allergies
50
40
32%
30
54%
20
10
32%
Patient's
Age
Comorbid
Conditions
Patient's
Weight
3%
3%
16%
None
of the
Above
16%
0
1
2
3
4
5
6
7
Results: Sample Medications
56% - no established
procedure for providing
prescription medication
samples to patients.
43%
Have
established
procedure
Only 6% of clinics label
samples for patients to use in
the home to assure proper
use.
6%
Label Samples
No
established
procedure
1
2
57%
Do Not Label
Samples
94%
Why do only 6% of offices
label the sample for the
patient before giving it to
them to take home?
Early attempt at medication safety system
Efficient use of
FTE’s…
Pharmaceutical
Representatives
are part of the
primary care
workforce too!
Results
Error Management
• 33% - no outlined procedure to respond to a
serious medication error
• 88% - reporting mechanism in place
Work Place Conditions
• 24% - dismissed individuals from
employment because of error
• 65% - reference errors in personnel files
• 71% - part of performance appraisal
Results – Areas for
Improvement

Data gathering and chart documentation


basic patient health information and current
medication history each change in care plan
Change what is included on a prescription



Indication
Date of birth, weight, allergies
High-risk co-morbid conditions
Results – Areas for
Improvement




Incorporate safe sample management
consistent with pharmacy practice standards
Use errors events to educate and improve
process, not punish individuals
Educate routine staff about strategies
designed to reduce errors
Incorporate no cost strategies to
prevent/reduce errors
Medication Safety Best Practices
Guideline Development


Survey items converted if met explicit criteria:
 Direct relevance to medication safety
 Increased risk if not attended to
 Feasible to implement solution
Practices identified into 3 implementation categories:
 Solution is individual behavior, no added resources
 Solution is in policy/system, no added resources
 Solution requires additional resources
Conclusion
Medication safety practices in the primary
care office are suboptimal to unacceptable
Improving the medication use process in
primary care offices is a critical step to
improving medication safety for the public.
Many solutions at no to low cost.
A best practices guideline may assist office
practices with these improvements.