Interventions to Improve Medication Safety in Primary Care Practice

Presenter: Kimberly A. Galt, Pharm.D., R.Ph., FASHP

Institution: Creighton University

Co-Authors: Eugene C. Rich, M.D., Wendy Taylor, BBL, Ann Rule, Pharm.D., J.D. Bramble, Ph.D, Wayne Young, Pharm.D., Bruce Houghton, M.D, Bartholemew Clark, Ph.D., Mark Siracuse, Ph.D., Ron Markert, Ph.D. Curt Barr, Pharm.D.

Introduction: A three-year study is in process to determine the impact of the use of personal digital assistants (PDAs) by prescribers on potential medication errors in primary care physician office-based practices. The aims are to: 1) measure the occurrence of potential preventable medication related errors in physician office-based practices; 2) assess physicians’ attitudes towards the PDA’s as reflected by frequency of use, ease of application to clinical situations, and confidence in the information obtained related to medications; 3) identify barriers perceived by M.D.s to PDA use in practice and successful strategies to overcome barriers; 4) determine the potential medication related errors reduction by physicians having improved access to pharmaceutical information needed at the point of care; and 5) determine the extent to which the frequency of potential medication related errors may be reduced by physicians using the PDA as a prescription printing device in office-based practice. To meet these aims, readiness assessments have been conducted on both the office-based practice sites and subjects. These assessments include office medication safety assessment survey, office and user technology readiness, and access to drug information/ pharmaceutical decision support resources at the point of care. This presentation provides findings related to these assessments and safety improvement recommendations.

Methods: A prospective, randomized, controlled trial of 80 physicians in 31 primary care office-based practices to observe the impact of PDA use on potential prescriber medication errors is in process. The physicians are randomized to an intervention group and a control group. The intervention involves training the physicians to use clinical information applications during the prescribing process through the PDA and entering and printing the prescriptions to a local printer via the PDA. The control group conducts their traditional prescribing practices throughout the study. An analysis of the individual subjects (user readiness) and their practice offices (office readiness) has identified barriers and solutions to technology adaptation and adoption. An assessment of office technology readiness was conducted through establishment of technology readiness criteria and a subsequent site visit using direct observation and office manager interviews. A drug/pharmaceutical decision support assessment to determine user access at the point of care was conducted. An office medication safety survey was developed to study the safety aspects of the medication use process that takes place in primary care practice, and to recommend practical improvements to enhance patient safety. This survey was administered using the interviewer-assisted technique to office managers. Direct observation was conducted to assess the environment, evaluate facilities, technologies, and office behaviors related to the medication use process.

Results: Office technology readiness. Almost half of the offices surveyed use Microsoft Windows 95 operating system. This no longer supports newer practice applications, including the hot-syncing requirements of handheld devices. One third report dial-up Internet connections with none reporting wireless connectivity. Almost all practices have their office-based computers networked and the network supports printers. Only two have infrared-enabled printers, a necessary feature to hand held device printing at point of care. One reports use of an early phase electronic medical record system. None report clinical computers in exam rooms where patients are seen. Less than half of the physicians use a computer in their routine daily practice. The most common applications for the office-based computers are communication, word processing, and information access. Drug /Pharmaceutical Information Access. Literature searches performed on the office-based computer rather than at the point of care are the most common applications reported. While many offices have access to clinical information via the Internet or other sources, there is no real time access. Drug information resources are either in the physician’s office or a central location; none in the patient examination rooms. Office Medication Safety. 44% have no specific procedure to respond to a serious medication error, 56% have no established procedure for providing prescription drug samples to patients; 6% label samples for patients to assure proper use, 36% report that pharmacists repeat back the prescription when they telephone prescriptions, 33% update the patients chart when they renew medications by phone, 24% report dismissing individuals from employment because of errors, and the indication for a medication is rarely included on the face of outpatient prescriptions written in office practice.

Conclusions: Our observations affirm that the present clinical information and technology infrastructure in many offices is insufficient to support use of PDAs. The small group practices are not well poised to implement and test technologies and applications. The office medication safety survey reveals suboptimal and sometimes unacceptable practices related to medication safety. Improving the medication use process in primary care offices is a critical step to improving medication safety for the public. Recommendations for improvements will be presented.