Preventing medication history errors in high-risk patients: Impact of California Senate Bill 1254

Link to article at PubMed

Am J Health Syst Pharm. 2023 Feb 13:zxad038. doi: 10.1093/ajhp/zxad038. Online ahead of print.


DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE: California Senate Bill (SB) 1254 (effective January 1, 2019) requires pharmacy staff at acute hospitals with more than 100 beds to obtain a medication profile for high-risk patients upon hospital admission. This multicenter study sought to evaluate the statewide impact of California SB 1254 by capturing the errors intercepted and harm prevented as a result of the passage of the bill.

METHODS: This was a multicenter, prospective, observational study conducted at 11 hospitals in California for 6 consecutive weeks between January 2020 and March 2020. Participating sites captured medication history errors identified among high-risk patients using organization-specific criteria. Errors were categorized by type and ranked for severity of potential or actual harm based on the modified National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) categories.

RESULTS: Study sites had an average daily census of 180 to 800 patients. Approximately 94% (n = 2,554) of medication histories conducted disclosed at least 1 error. Approximately 54% (n = 1,474) of histories disclosed at least 1 serious or potentially life-threatening error. Approximately 6 errors were identified and prevented per patient (95% CI, 5.62-6.01 errors per patient), and 1 in 4 errors (25%) was categorized as potentially serious or life-threatening.

CONCLUSION: Among high-risk patients, pharmacy-led medication histories significantly reduced medication errors. If not intercepted, these errors would have likely resulted in substantial morbidity and mortality. Future research should evaluate opportunities to standardize high-risk criteria to support patient prioritization and allocation of resources.

PMID:36775982 | DOI:10.1093/ajhp/zxad038

Leave a Reply

Your email address will not be published. Required fields are marked *