262: Improving error identification with an inpatient maternal-fetal medicine pharmacist

Abstract

Although the fast-paced environment of inpatient obstetrics may predispose to medication errors, there is relatively little information about their nature and frequency. In September 2017, our Midwestern level-IV hospital hired a dedicated inpatient maternal-fetal medicine clinical pharmacy specialist. The pharmacist attends daily board rounds on labor and delivery, rounds on all antepartum patients, and monitors medication orders. The objectives of this quality improvement study were to: (1) quantify the number and types of interventions made by the pharmacist and (2) to compare rates of reported errors before and after her hiring. We hypothesized that the rate of identified medication errors would be increased in the time period after the pharmacist was employed. From February 1, 2018 through May 31, 2018, the pharmacist tabulated her interventions on a daily basis under the categories of medication error, drug interactions, monitoring, cost savings, medication management, and other. The number and types of medication errors reported to our institutional event reporting system in the eight months prior to and first eight months after the pharmacist’s hiring were compared. Figure 1 depicts the number of interventions (n=1,217) within the different categories per month. The most frequent interventions were discontinuation of medications that were no longer indicated (n=232), providing drug information/education of clinical staff (n=251), and providing initial dose recommendations (n=116). There were 74 cost-saving interventions. The number of reported medication errors (n=71) to the centralized reporting system doubled (3/month to 6/month, p=0.007) after the pharmacist’s hiring (Figure 2), and the majority of these were reported by the pharmacist herself. The most frequent types of errors were wrong dose, route, or schedule (n=33) and medication not given or given without order (n=18). In the initial months after commencing her role, the pharmacist provided over 1,000 direct clinical interventions to improve patient care in a high-risk environment. Furthermore, medical errors can only be systematically addressed when they are noticed, and this study highlights that a significant proportion of medication errors (50% in this study) are not reported by providers. These results suggest the addition of a pharmacist to the obstetric team may lead to interventions which ultimately improve medication safety.View Large Image Figure ViewerDownload Hi-res image Download (PPT)