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Studies examine dispensing of sample medications and preventing medication errors in primary care practices

Primary care doctors often distribute sample medications to their patients. Yet a new study of 17 primary care practices revealed that none of them followed guidelines for the safe dispensing of medication samples. Another study found that a safety culture in primary care practices, which encourages patients and staff to ask questions and be vigilant, can prevent medication errors from harming patients. Both studies were supported by the Agency for Healthcare Research and Quality (HS11878) and are summarized here.

Hansen, L.B., Saseen, J.J., Westfall, J.M., and others (2006, December). "Evaluating sample medications in primary care: A practice-based research network study." Journal on Quality and Patient Safety 32(12), pp. 688-692.

When doctors give patients medication samples, the samples should be labeled and include the patient's name, the reason for the medication, the dose and how often the medicine should be taken, special precautions for use, and any significant side effects that can be expected. Yet none of 17 urban and rural primary care practices studied in 2004 complied with all of these recommendations. Only 7 practices followed the recommendation for sample labeling, and only 12 practices had policies for dispensing sample medication.

Overall, 58 sample medications were dispensed during 9 percent of 585 patient visits. Doctors cited sample availability and the need for a short-term trial of a chronic medication as common reasons for using sample medications. Most of the time, they only verbally communicated to patients the appropriate sample medication use and potential side effects that could increase the risk for medication errors.

The most commonly used sample medications were antihypertensives (17.7 percent) and cough/cold/allergy agents (9 percent). According to 27 patient surveys, instructions on how to use the sample medications were provided only through verbal communication from the doctor or nurse in 70 percent of cases, verbal and written instructions in 30 percent of cases, and only written instructions in 4 percent of cases. Some patients received no information about special instructions or side effects.

Parnes, B., Fernald, D., Quintela, J., and others (2007, February). "Stopping the error cascade: A report on ameliorators from the ASIPS collaborative." Quality and Safety in Health Care 16, pp. 12-16.

A pervasive culture of safety in primary care practices, which builds on simple acts and electronic safety systems, may improve patient outcomes. Medical staff and patients who were encouraged to be vigilant, ask questions, and seek solutions were able in many cases to catch medical errors before they could harm the patient. Over a 3-year period, clinicians and staff in two primary care practice-based research networks voluntarily reported medical errors to a safety reporting system.

The researchers found a number of reports where the error was corrected before it had an adverse impact on the patient. For example, of 754 reported events, 60 were classified as ameliorated events. In these cases, an ameliorator identified the error and took corrective action to prevent the error from reaching and harming the patient. For example, if the patient was given a written prescription in which the dosage was unclear, the pharmacy called the clinic to clarify and ensure the proper dosage.

In another situation, a physician noticed that a patient's hip x-ray abnormality did not correspond to the hip side the patient was complaining about, which led to identification of an incorrectly labeled x-ray. Ameliorators included doctors, nurses, pharmacists, diagnostic laboratories, and office staff. In 15 percent of cases, patients or family members acted as ameliorators by recognizing an error and taking action. Amelioration likely occurs routinely as clinicians and staff correct errors as a matter of course.

This study examined how they take action to interrupt the cascade before it affects the patient. System fixes can be effective in stopping cascades by catching mistakes and directing action. However, chance plays a role in uncovering other problems. Even in cases in which errors are detected, there must be enough time to correct them before they affect patients, and potential ameliorators must have the resolve to follow through with corrective action. These findings reinforce the need for a medical culture that empowers all stakeholders to ask questions and act to prevent errors.

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