- Every healthcare organization, including Long Term Care, has a duty to continually improve systems to prevent harm to patients due to medication errors.
- Health care organizations have to monitor actual and potential medication errors that occur.
- The value of medication error reports and other data gathering strategies is to provide the information that allows an organization to identify weaknesses in its medication use system and to apply lessons learned to improve the system.
- The healthcare organization’s, prevention of medication errors is only as strong as its weakest link. Determining the weakest link in your system is challenging and takes consistent analysis, documentation,
coordination, education as well as consistent and impartial communication.
- The number of error reports is not as important as the quality of the information collected in the reports, the Long Term Care organization’s analysis of the information, and its actions to improve the system to prevent harm to patients. Therefore, there is no acceptable incidence rate for medication errors. Furthermore, the use of medication error rates to compare health care organizations is of no value.
Reference accessed 3/8/19: Statement on Medication Error Rates
VISIT: National Coordinating Council for Medication Error Preventions [NCCMERP]
• Index for Categorizing Medication Errors
• Index for Categorizing Medication Errors Algorithm
Jennifer Hamilton, Pharm D, BCGP is a Consultant Pharmacist with Holladay Healthcare Pharmacy.
- Know your medications by name. If you know the name of your medications, you will be able to be sure that you are receiving the right medication each time you get it.
- Ask questions about your medications. Some questions you may have: Why is the tablet a different color this time than it was the last time? What should I do if I miss a dose of the medication? Should I take the medication with food?
- Know what your medications are being used for. If you are aware of what each medication is being used for, it will help you remember to use it appropriately.
- Read medication labels and follow the directions. It is important to follow the directions of each medication carefully to avoid any unwanted side effects.
- Keep your doctors informed of your current medication list. This will help eliminate duplicate medication therapy.
- Keep your complete medication list with you at all times. It is a good idea to also be sure a loved one is aware of the medications you take in order to help you in the case of an emergency.
Jessica Higgins, PharmD
Director of Consultant Services
Holladay Healthcare Pharmacy
Please contact Holladay Pharmacy at 1-800-848-3446 if you have questions.
You’ve probably heard about the Ketogenic diet by now. Celebrities are losing weight and touting its benefits. If you haven’t heard, the ketogenic diet is a way of eating that restricts carbohydrates, includes moderate protein and high fat.
There are a growing number of physicians who don’t think a well-formulated keto diet is a fad but actually a very safe and effective way to not only lose weight, but to reverse diabetes. More than 1.4 million people are diagnosed with type 2 diabetes every day in the US. One in every 10 adults who are 20 years or older has diabetes. For seniors 65 years and older, that figure rises to more than one in four. It appears that a low carbohydrate diet is a safe and effective way to treat Type 2 diabetes.
Dr. Sarah Hallberg, a physician at the University of Indiana, has published one-year data from a study* for which she is the primary investigator where 349 patients were enrolled in either the study arm (262 people) or chose usual care (87 people). Patients in the study had type 2 diabetes for an average of 8.4 years and the average BMI was 40. After 12 months the average HgbA1c for study patients decreased from 7.6 to 6.3. Patients in the usual care arm had no change. Also, patients in the study arm lost an average of 30 pounds (13.2% of body weight). 94% of patients in the study arm either discontinued or reduced their insulin need and many of their other diabetes medications. Patients in the usual care arm increased their insulin requirement by an average of 15 units/per day.
One of the questions many physicians have about the keto diet is what happens to biomarkers for cardiovascular risk? While the LDL–C (“bad cholesterol”) went up slightly in patients in the study, the LDL-P (particle size) decreased and APO-B remained the same. HDL (“ good cholesterol” ) was increased and triglycerides went down.
Dr. Hallberg and her group hope to publish the two-year data sometime in early 2019. Stay tuned!
* Hallberg SJ, McKenzie AL, Williams P, et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at One Year: An Open Label, Non-Randomized, Controlled Study. Diabetes Therapy. 2018; 9(2): 583-612. doi: 10.1007/s13300-018-0373-9
Please contact Holladay Pharmacy at 1-800-848-3446 if you have questions regarding the Ketogenic Diet.
Shingrix is the new shingles vaccine on the block; and it has led to some confusion among healthcare providers. This has led to a number of reported medication errors via the Vaccine Adverse Event Reporting System (VAERS). Errors have included incorrect storage, wrong route of administration, and incorrect reconstitution.
There are some key differences to make note of between Shingrix and the older Zostavax vaccine. First and foremost, Shingrix is not a live vaccine (Zostavax is live). Shingrix is supplied as a 2-vial set containing 1 vial of lyophilized varicella zoster virus glycoprotein E antigen and a single dose vial of AS01B adjuvant suspension. The antigen component must be reconstituted with the adjuvant suspension. While the Zostavax virus was to be stored frozen, the new Shingrix vaccine is stored refrigerated between 36-46 o F.
Also, the route of administration differs in that Shingrix is given as an intramuscular injection while Zostavax is subcutaneous. Shingrix is given in 2 separate doses. The second dose is administered 2-6 months after the first dose. Shingrix is also now the preferred vaccine to prevent herpes zoster.
Please contact Holladay Pharmacy at 1-800-848-3446 if you have questions regarding this new vaccine.