As a pharmacy professional, it’s important to understand how medication incidents can happen when prescriptions are unclear or there is poor collaboration between health care providers. Poor communication within a patient’s circle of care was often reported when there was a change in the patient’s medication, dose, or regimen.
Incident Examples from Manitoba Community Pharmacies
A patient’s INR was found to be 3.6 on a daily dose of warfarin 2 mg. The prescriber then indicated on the electronic medical record for home care to decrease warfarin to alternating doses of 2 mg and 1.5 mg daily. The prescriber faxed the pharmacy a prescription for warfarin 1.5 mg daily (and confirmed a reduction from 2 mg daily to 1.5 mg daily), and the new dose was sent to the home. However, the nurse administered the incorrect dose because the note in the medical record did not correlate with the instructions on the pharmacy label.
Leveraging Standardized Communication to Prevent Medication Incidents
To prevent medication incidents like one described above, it’s essential to have seamless and timely transfer of key medication information among multiple health care professionals in different care sectors. This means developing a standardized method of communication between all members of the circle of care, especially during transitions of care.
One key recommendation for ensuring medication safety is to include a copy of the prescriber’s order when a new medication or dose is sent to another health care professional like the home care nurse in the incident example. This way, everyone involved in the patient’s care can have access to the same information and instructions, reducing the likelihood of medication errors due to miscommunication.
Communication between health care providers is critical to preventing medication incidents. By developing standardized methods of verbal and written communication and including copies of prescriber’s orders, we can ensure that everyone involved in a patient’s care has access to the same information and instructions, improving medication safety for all.
