By Ronald WolfDecember 11, 2019
NATIONAL HARBOR, Maryland - The pharmacy department at U.S. Army Medical Activity (MEDDAC) Bavaria was awarded High Reliability Award, Patient Safety Category, at the Association of Military Surgeons of the United States (AMSUS) Annual Meeting on December 5, 2019.
"Patient quality and safety are high priorities for any health care system. To be the best in military medicine, the pharmacy department at Bavaria MEDDAC actively looked for ways to improve patient safety. They had good reasons to do so: according to the Institute of Medicine's Preventing Medication Errors, there are 4 errors for every 250 prescriptions dispensed," said Richard Juneau, MEDDAC Bavaria polypharmacy pharmacist,, who represented MEDDAC Bavaria during the AMSUS Awards Banquet.
The team at Bavaria MEDDAC developed a method to reduce provider order entry (POE) near-miss errors to decrease the number of incorrect prescriptions dispensed. The goal was a reduction of pharmacist interventions by 50% for these repetitive near-miss errors. To accomplish this, they did the following:
-- Internalized the documentation of provider order entry near-miss errors into the pharmacy review process.
-- Developed a list of edit codes using a failure mode and effects analysis and data analysis. This structured approach helps to identify potential failures that may exist within the design of a process.
-- Developed a method to obtain audit trail data within the Composite Health Care System (CHCS) using its ad hoc report feature.
-- Increased the transparency of data for the identification of trends and communication vertically and horizontally across the organization.
The process positively impacted the number of near-miss errors. There was a 64% decrease in the near-miss errors requiring provider contact and the rate of near-miss errors per new prescriptions has remained under the goal of 4%.
"By implementing POE near miss error edit codes, trending the causes of near miss errors, and increasing the transparency of the data, they demonstrated the utmost stewardship for medication safety," said Juneau.
The AMSUS Annual Meeting is for military healthcare professionals and leaders to improve the effectiveness, cohesiveness, and esprit de corps of the federal healthcare services. This year's meeting theme is, "Transforming Healthcare through Partnership and Innovation."