Safe Switch Initiative: Medication Safety Focusing on Therapeutic Interchange in Ambulatory Care

Indianapolis, IN

The Institute of Medicine (IOM) estimates 1.5 million preventable adverse drug events (ADEs) occur in theUnited Stateseach year. The total annual cost for these preventable ADEs is estimated around 3.5 billion dollars yearly. Medications errors can result in increased side effects, sub-therapeutic dosing, overdosing, coma, and death. The St. Vincent Joshua Max Simon Primary Care Center (PCC) Outpatient Pharmacy is associated with St. Vincent Health System, allowing for a closed formulary and therapeutic interchanges. In order to offset risks with potential medication errors, the PCC pharmacy has implemented a patient counseling and follow-up process called the Safe Switch Initiative (SSI). This process is implemented by pharmacy students and residents and is designed to reinforce information to the patient regarding therapeutic interchanges. There are two main objectives. First, to determine the number of medication errors or near misses with institution specific high risk medications including oral hypoglycemic agents, insulin, angiotensin receptor blockers (ARBs), beta blockers (BB), non-steroidal anti-inflammatory drugs (NSAIDs), and statins. Second, to determine if different drug classes are more likely to be associated with medication errors. This study is a retrospective, observational study and was approved by the Institutional Review Board. Established PCC patients who had a therapeutic interchange with a previously determined high risk medication were included in the study. Patients were excluded if under 18 years of age, pregnant, or received a prescription from the hospital approved by social services. Review of patient charts and SSI documentation began in September 2013 and will continue through February 2014. The following data is being collected: age, sex, primary clinic, current medications, high-alert medications, and duplicate medications or classes. All information has been recorded without patient identifiers to maintain confidentiality. Data collected will be analyzed using statistical tests appropriate to the type of data.