Saturday, September 10, 2005

Medication Errors: Hospital Pharmacist Perspective

We found a very interesting article concerning the medication errors in the website of the Hospital Pharmacists Association of the Netherlands (Nederlandse Vereniging van Ziekenhuisapothekers (NVZA) (

This article critically examines possible interventions aimed at reducing medication errors and the role of the pharmacist in these interventions.

Topics covered include:

* Adverse Drug Events (ADEs),
* Risk Assessment in Clinical Pharmacy,
* The Drug Distribution Chain (Medical Diagnosis, Drug Choice, Precribing, Dispensing, Preparation, Barcode-Enabled Point of Care Systems) and
* The role of the clinical pharmacist

Here is the abstract:

Drugs 2005; 65 (13): 1735-1746
2005 Adis Data Information BV. All rights reserved.

Medication Errors
Hospital Pharmacist Perspective

Henk-Jan Guchelaar,1 Hadewig B.B. Colen,2 Mathijs D. Kalmeijer,3
Patrick T.W. Hudson4 and Irene M. Teepe-Twiss1

1 Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
2 Department of Clinical Pharmacy, Medical Spectrum Twente, Enschede, The Netherlands
3 Department of Clinical Pharmacy, Academic Medical Center, Amsterdam, The Netherlands
4 Department of Psychology, Center for Safety Science, Faculty of Social and Behavioural Sciences, Leiden University, Leiden, The Netherlands


In recent years medication error has justly received considerable attention, as it causes substantial mortality, morbidity and additional healthcare costs. Risk
assessment models, adapted from commercial aviation and the oil and gas industries, are currently being developed for use in clinical pharmacy.
The hospital pharmacist is best placed to oversee the quality of the entire drug
distribution chain, from prescribing, drug choice, dispensing and preparation to
the administration of drugs, and can fulfil a vital role in improving medication
safety. Most elements of the drug distribution chain can be optimised; however,
because comparative intervention studies are scarce, there is little scientific
evidence available demonstrating improvements in medication safety through
such interventions.
Possible interventions aimed at reducing medication errors, such as developing
methods for detection of patients with increased risk of adverse drug events,
performing risk assessment in clinical pharmacy and optimising the drug distribution chain are discussed. Moreover, the specific role of the clinical pharmacist in improving medication safety is highlighted, both at an organisational level and in individual patient care.

You can download the whole article from the address: