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Early lessons from a new patient safety initiative outline a pathway to reduce medication-related harm.
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Early Lessons to Reduce Medication Harm

By Christian Ayin | Wednesday, May 29, 2019

In the early years of my career as a pharmacist, I had an experience that made me zealous about addressing challenges associated with medication-related harm. A midwife asked me to get a glucometer for a pregnant patient with diabetes to monitor her blood glucose (blood sugar) level. When the woman delivered a baby girl, the midwife told the staff, which got us all excited. Later, I met this woman again, screaming and wailing at the outpatient clinic. She broke the sad news of the passing of her 6-month-old baby. I learned she unfortunately most likely lost her baby because of hypoglycaemia (very low blood sugar), caused after insulin — a diabetes treatment known to be very safe in pregnant and breastfeeding mothers — was replaced with glibenclamide, which is known to be less safe, at a routine hospital visit. The health system did not prevent an individual error from reaching the woman and her child and causing serious harm. This experience has stuck with me and primed me to always look out for harms due to medicines and offer help the best possible way that I can to colleagues, staff, and clients.

Last year, my hospital’s medical director and I were nominated by management to represent the facility at the launch of the Africa Hospital Patient Safety Initiative in Accra, Ghana. I attended the first learning session where I was introduced to several tools and design frameworks for the medication-related harm project. Since this session, I have played a vital role in the formation of a safety team to carry out this project in our hospital.My role includes randomly selecting inpatient records to study, working with other team members to retrieve primary records, manually reviewing records to identify adverse events or harms experienced during admission using the IHI Global Trigger Tool, and sending reports of findings to project partners.

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While looking for medication-related harm, we found an unexpected proportion of emergency room visits due to adverse events caused by herbal medicines. These harms have led to prolonged hospitalizations and the need for timely interventions to save lives. During the trial period of collecting data, I found that unlabelled, unprescribed herbal medicines were causing adverse events much like traditional high-alert medicines such as treatments for high blood pressure. Adverse events associated with herbal medicines included allergic reactions, hypoglycaemia, anaemia (lack of healthy red blood cells), and gastroenteritis (inflammation of the intestines). I realized my hospital will have to include herbal medicines as one of our high-alert medicines. Amazing how this never crossed my mind during the last learning session when we had the opportunity to update the list of high-alert medicines. In the future, we plan to further investigate the burden of harm due to herbal medicines.

In addition, I have been quite surprised by the number of adverse events caused by giving a patient a medication despite it previously being documented that the patient reacts negatively to it. While reading through case notes, I came across a patient who had been treated with one medication for blood pressure three different times by different prescribers, even though it had been documented in his notes that he reacts negatively to this medication. On all three occasions the patient reacted and reported the reactions during his visits.

Lessons learned from this work include:

  1. Educating patients on the risks of herbal medicines is essential.
  2. We must not only document all patient allergies, but also make sure this data is readily available to doctors and other health care workers, so they can make informed decisions regarding patient medication reviews as a crucial part of negative reactions.
  3. We need to support patients in knowing their own drug allergies and advocating for themselves in medication-related decisions as an additional resource in the system.

Going forward, the team will share the experiences from the learning sessions with the other staff to continue addressing these opportunities for improvement. Together, the team will work with staff to identify and implement change ideas to improve the current situation and also engage patients and other organized groups to share findings with them. For example, the team is currently contemplating using a drug allergy passport — a small card indicating the drugs that the patient reacts to which could be attached to patient health insurance card.

Christian Ayin, MPH, is a pharmacist at St. Luke Catholic Hospital, Apam, Ghana.

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