5PSQ-021 Prescription errors associated with on-demand medication reconciliation at admission: sublingual nitroglycerin as an example

• Published in: European journal of hospital pharmacy. Science and practice 2018-03, Vol.25 (Suppl 1), p.A174-A174
• Main Authors: Menéndez, JA Domínguez, Izquierdo, I Ibarrola, Erviti, M Arrastia, Urtizberea, U Blazquez, Aguirre, I Martinez, Santos, N Pardo, Barrenechea, LM Mendarte, Ibarreche, MJ Yurrebaso
• Format: Article
• Language: English
• Subjects: Drug dosages; Medical errors; Physicians; Prescriptions; Primary care; Section 5: Patient safety and quality assurance
• ISSN: 2047-9956; 2047-9964
• DOI: 10.1136/ejhpharm-2018-eahpconf.375

BackgroundIn primary care the computerised physician order entry system (CPOES), treatments on demand must have an associated fixed schedule. This is use in order to calculate monthly collection of the medication.At hospital admission, usually on-demand home medication is prescribed with a fixed schedule, causing potential medication errors. Sublingual (sl) nitroglycerin is one of the most implicated drugs in this type of error.PurposeTo estimate and analyse the incidence of medication errors due to the incorrect prescription of on-demand home treatment. To analyse the prescription of sl nitroglycerin.Material and methodsRetrospective observational study of a 15-day- period. Only patients with home medications (chronic or on-demand) were included, and were reviewed and registered the day after admission. Analgesics and proton-pump inhibitors were excluded because of the high usein hospital. On-demand medication prescribed with a fixed schedule without justification was considered incorrect.Retrospective analysis of sl nitroglycerin prescription over 60 days, excluding patients receiving just one dose, or treatment initiated in hospital. Prescriptions with a fixed schedule and without indications were considered wrong. Prescription correction by pharmacists was also taken into account.ResultsHome treatment of 122 patients was analysed (average age 69; 62 females; average drugs four). From 488 medications, 25 were prescribed on demand (0.2/patient), and 11 (2.25%) were prescribed in a fixed schedule incorrectly in eight patients. Ten of the mistakes occurred in surgical services (7/48 inpatients), and one in non-surgical services (1/74 inpatients). In six of these, at least one dose was administered. Implicated medicines: terbutaline (two), salbutamol, sl nitroglycerin, mepyramine, tramadol, furosemide, olopatadine, ebastine, mometasone and loperamide.Sl nitroglycerin prescriptions of 30 inpatients were analysed (average age 76; 18 males). Eighteen prescriptions were incorrect (60%): 17 errors in 20 surgical patients and one in non-surgical (psychiatry service). All incorrect prescriptions were corrected by pharmacists at admission, so no medication error occurred.ConclusionCPOES can be a source of new errors, not observed until its introduction, so pharmaceutical validation is essential in its detection and correction. To prevent these mistakes, primary care CPOES modification and continuous practice are necessary, especially in surgical services.No conflic