Observational study of consumer role and awareness in checking medications

ISSUE: Medication errors are the single most common type of adverse event. The Institute for Safe Medication Practices reported in 2002 that one out of every 20 prescriptions filled in a pharmacy has an error. While many hospitals and pharmacies are trying to reduce the prevalence of medication errors in a variety of ways, consumers must take an active role in protecting themselves from potential errors of this kind. Therefore, we evaluated how actively involved consumers are in protecting themselves against medication errors by observing their behavior when picking up prescriptions.

PROJECT: Observed all individuals who came to pick up a prescription at a specific selection of pharmacies in and around an urban academic institution. By blending into the waiting area, we noted a selection of characteristics about each consumer including: gender, age, race, whether the consumer looked in his medicine bag during the time in which he was visible to us, whether the consumer asked questions of the pharmacist, whether the pharmacist asked the consumer if he had any questions, and whether there were any other significant, distinguishing characteristics about each interaction.

RESULTS: The sample size for this study consisted of 220 observed interactions. Fourteen percent (14%) of observed consumers looked in their medicine bags before leaving the pharmacy, and 18% of observed consumers asked medication questions of their pharmacist. Some pharmacists were better than others about actively asking consumers if they had any questions about their medication. Overall, 23% of observed pharmacists asked the consumers if they had any questions about their medication. Other factors such as workload and the number of other pharmacists available influenced whether or not the pharmacists engaged with the consumers and whether or not the consumers had a chance to ask questions.

LESSONS LEARNED: The majority of observed consumers did not play an active role in preventing medication errors, suggesting a need for a new, more active protocol to get the average consumer more interested in their own healthcare. A simple reminder poster or card on the counter where the interaction between the pharmacist and consumer takes place may decrease medication errors.

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