Medication safety has drawn renewed national scrutiny after Ascension St. Thomas Hospital Midtown in Nashville, Tenn., confirmed that four joint replacement patients were mistakenly injected with potassium phosphate instead of the anesthetic mepivacaine Aug. 14.
A state survey later found the hospital had been placed in immediate jeopardy on three CMS conditions of participation, tracing the error to a sterile-compounding process in which a pharmacy technician selected look-alike vials, a second technician labeled the syringes without visually checking them and the hospital’s compounding software allowed staff to bypass barcode scanning altogether.
It is not the first case to reshape how hospitals think about medication safety. The 2017 death of a patient at Vanderbilt University Medical Center, also in Nashville, Tenn., after a nurse overrode a medication cabinet and withdrew the paralytic vecuronium instead of the sedative Versed, led to a criminal conviction and prompted hospitals nationwide to re-examine their own safeguards.
But medication error rates are difficult to trend nationally, making it difficult to assess industry progress, according to Rita Jew, PharmD, president of the Institute for Safe Medication Practices. Errors are largely voluntarily reported, and even where reporting is required by law, it remains significantly underreported. Reporting volume is also shaped by an “outcome bias,” Dr. Jew said. Incidents with visible patient harm get reported more consistently than near misses that could have caused the same harm but didn’t. That makes reporting volume itself a poor safety indicator. “Does that mean that they are not safe?” Dr. Jew said of organizations with high error-report counts. “Or does that mean that organizations that don’t have a lot of reports are safer?”
What can be gleaned, she said, are directional signals from published research, which show adverse drug events remain among the most common forms of patient harm in hospitals, and meaningful work remains to reduce them. Within ISMP’s own voluntary reporting system, errors surface at every point in the medication-use process, she said, from ordering and dispensing to administration, monitoring, procurement and storage.
“Safety work is not glamorous,” Dr. Jew said. “It requires a lot of persistence because you have to keep monitoring it, and you can’t just implement some safety action plans and walk away from it.”
At Allegheny Health Network in Pittsburgh, Laura Mark, PharmD, vice president of pharmacy, told Becker’s the system began a major push around 2017 or 2018 to standardize technology and workflows across all 10 of its hospitals, including barcode medication dispensing, radio-frequency ID tracking of medications and equipment, and an IV technology-assisted workflow that now covers more than 90% of the system’s IV preparations.
At OSF HealthCare in Peoria, Ill., Sandra Salverson, PharmD, senior vice president and chief pharmacy officer, described a similar emphasis on consistency across the system’s hospitals, paired with barcode scanning embedded from product receipt through dispensing, compounding and administration. An error or pattern identified at one location prompts a systemwide risk assessment rather than a local fix, Dr. Salverson said.
OSF also tracks a combination of process and outcome measures rather than a single indicator, Dr. Salverson said, including barcode scanning compliance across dispensing, compounding and administration, smart pump utilization, and clinical outcomes such as medication-induced acute kidney injury rates and anticoagulation outcomes across transitions of care.
At AHN, that ongoing scrutiny extends beyond the hospital floor. For instance, the system’s newest initiative extends barcode scanning to vaccines administered in its outpatient clinics, a reminder, Dr. Mark said, that medication safety strategy can’t stop at the hospital’s front door.
At Sharp HealthCare in San Diego, Suzanne Shea, vice president of pharmacy, described a layering of safeguards at every stage of the medication-use process. Clinical decision support is built into orders placed in Epic, and a points-based scoring system flags higher-risk patients, incorporating lab values and clinical context, for deeper pharmacist review. On inpatient units, medications are managed through BD Pyxis stations with everything on profile, smart infusion pumps and bedside barcode scanning.
Within the pharmacy itself, the most common catch point is mislabeling during packaging, Ms. Shea said, which the system addresses by barcoding medications at the shelf, in hand and again at the bag before anything leaves the pharmacy.
Sharp also maintains a system-level team of medication safety pharmacists who meet routinely across its hospitals, along with a dedicated regulatory pharmacist who conducts unannounced internal reviews modeled on Joint Commission and state board of pharmacy surveys.
The 2017 Vanderbilt case, in which nurse RaDonda Vaught typed only two or three letters into a medication cabinet’s search function and selected the wrong drug, prompted concrete changes at Sharp, Ms. Shea said, including reprogramming its Pyxis med stations to require at least five letters of a drug name before generating a search result, matching a change ISMP recommended industrywide. Sharp also expanded its use of tall-man lettering and physically separated look-alike drugs across its dispensing devices.
None of the leaders described these safeguards as purely technical. Dr. Mark pointed to a framing AHN builds into its safety strategy that goes beyond patient harm: protecting staff from becoming what patient safety experts call the “second victim” of an error.
“If it happens to a pharmacist or a technician and they create that error, we did not put systems in place to help them with preventing that,” she said. “We don’t want to ever put our pharmacists or technicians in a position where this could happen to them.”
Sharp runs a cross-functional safety steering group, including nurses, quality managers, pharmacists, physicians and chief nursing officers, that opens each meeting with a real patient story or a “great catch,” Ms. Shea’s team’s term for a near miss that was caught before it reached a patient.
“We do a lot of storytelling at Sharp, honestly, to talk about what’s gone on with our patients,” Shea said, “and to raise up the idea that everybody’s in charge of medication safety and patient safety.”
At OSF, Dr. Salverson pointed to “Just Culture” practices that also include sharing good-catch stories and lessons learned from errors, along with a proactive safety assessment for any new medication before it reaches a patient. “Technology is only one part of medication safety,” she said. “Even in challenging circumstances, safety is not a tradeoff.”
Even with those layers in place, none of the three leaders described their systems as finished. Dr. Mark was candid that much of the industry still has progress to make, particularly at smaller or less-resourced systems, since safety technology like IV-assisted workflows often carries real costs without a direct financial return, and reimbursement pressures limit how much systems can reinvest in tools that exist purely to prevent harm.
And even where the technology is in place, her biggest current worry isn’t a gap in the tools themselves but staff working around the safeguards already built into them. When a system triggers a stop, she said, “that’s probably the piece with technology that is just in general fearful — that people bypass it.”
At the Becker's 11th Annual IT + Revenue Cycle Conference: The Future of AI & Digital Health, taking place September 14–17 in Chicago, healthcare executives and digital leaders from across the country will come together to explore how AI, interoperability, cybersecurity, and revenue cycle innovation are transforming care delivery, strengthening financial performance, and driving the next era of digital health. Apply for complimentary registration now.
