Medication management is a process. Every center has their own way of managing this process whether it is manual, electronic or a combination, however, it is not a perfect process no matter how we do it. Sadly, 7,000 to 9,000 people die every year due to medication errors. Per the National Library of Medicine, the most common reasons for errors include failure to communicate drug orders, illegible handwriting, wrong drug selection chosen from a drop-down menu, confusion over similarly named drugs, confusion over similar packaging between products, or errors involving dosing units or weight.
What isn’t in this list is a failure to HAVE the medication available, an issue that many of our centers face on a daily basis. How about this headline “Bend woman sues St. Charles Health System, alleging negligence”. The suit was filed when a patient had a delay in renewing a prescription that allegedly resulted in her experiencing a stroke, leaving her handicapped with difficulty speaking. In this case, the woman missed a total of two (2) days of her medication, that’s how quickly negative outcomes can happen when medication regimes are disrupted. In this situation, the plaintiff is seeking $999,500 in damages, do you have deep pockets?
If you are lucky enough to always have medications at your fingertips, good for you! If you aren’t or aren’t sure, maybe you need to do a deeper dive into your process. Think about it, two (2) days, that’s all it took for a negative outcome for the patient in Bend. Take a walk around your center, talk to your nurses, ask the questions! Look at your MARs and/or your exception reports on the eMAR, are medications “unavailable”? Are residents not receiving their medications due to pharmacy delays? If so, why? Are delays or “unavailable” medications an internal problem with failure to order timely or a pharmacy/delivery issue? Think about adding your pharmacy provider to your next QAPI agenda, discuss the process so that you understand it and the pharmacy understands your expectations. You can never be too sure when it comes to caring for your residents and protecting your staff. Stay well and stay informed!