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Minneapolis Hospital Director Gets Proactive on Medication Errors

David W. Hodges
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Partner at Kennedy Hodges LLP practicing pharmacy error, medical malpractice and personal injury law
Posted on Jan 26, 2012
A Minnesota hospital’s pharmacy services director has found a way to stop harmful medication errors before they happen, saving patients from potentially life-threatening prescription drug mistakes.
Director Bruce Thompson, ordered spot-checks of 37 patients who were recently discharged from Hennepin County Medical Center after a string of patient “bounce backs” pointed to medication errors.  The staff found that the facility’s record left something to be desired: 92 percent of all medication orders had some kind of error.
For example, a kidney transplant patient was discharged from HCMC with an incorrect dose of antibiotics. Another patient who recently suffered a pulmonary embolism was sent home without a crucial blood thinner prescription.  Both cases resulted in the patients returning to the hospital.
Thompson reported that the most common errors involved physicians prescribing an incorrect dose, patients taking duplicate medications or a lack of drug interaction detection.  One-third of the potential mistakes were classified as “likely harmful."
The hospital instituted a new program in response: assign a pharmacist to check all discharge orders before patients are released from the hospital. In a little less than one year, the medication error rate has dropped to a negligible level and cut patient readmission rates in half.
Hennepin County Medical Center was celebrated for its results, garnering The Institute for Safe Medication Practices’ 13th annual "Cheers Award" for "excellence in the prevention" of medication errors.
Thompson has responded to calls from hospitals nationwide, encouraging them to start a similar program in their own facility.  He also says that some doctors now start their prescriptions by calling the pharmacist to confirm and check the order.   

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