HOSPITAL PRACTICE

LEAVING LAS VEGAS

Medication errors, staff shortages top list of hot topics at well-attended ASHP meeting

What do you get when you mix pharmacists, cowboys, and music superstars? An unusual week, even by Las Vegas standards. The rodeo cowboys were in town attending the National Rodeo Finals, and pop idols performed at the Billboard Music Awards. The cowboys definitely had better hats and the musicians were more stylish, but it was clearly the health-system pharmacists who took the week and center stage. More than 20,000 pharmacists converged on this desert town over a four-day period, a record-shattering attendance for an ASHP Midyear Clinical Meeting. While outside on the Vegas strip the odd blend of visitors made for some interesting theater, inside the convention center ASHP presented some compelling theater of its own during the opening general session.

In a departure from its usual keynote speaker format, ASHP presented "Anatomy of an Error," a dramatization depicting events leading up to a medication dosing error that caused harm to a patient. It featured doctors, pharmacists, and nurses, who explained the individual role they played in the medication delivery system that eventually led to the error. It underscored the notion that not any single individual or incident is responsible for an error but that the flaws in an entire system combine to create a climate conducive to mistakes. Following the presentation, which also managed to convey the devastating impact a med error can have on health-care practitioners, a father/ health-care executive spoke of losing a daughter to cancer—but not before she was the victim of several drug errors.

This opening theme resonated throughout the meeting. At least a half a dozen seminars and exhibitor's theaters addressed various medication error topics. Two of the more notable sessions included: the role of automation in improving quality and reducing med errors, and the part that certified pharmacy technicians play in preventing and resolving these bloopers.

ASHP also released the results of a survey of pharmacy practice in acute care. Among the data extrapolated from the survey:

• Sixty percent of respondents said they reported adverse drug events (ADEs) to external organizations.

• When ADEs are reported externally, 92% of the pharmacists are likely to send the information on to the Food & Drug Administration, 27% to the drug manufacturers, 17% to U.S. Pharmacopeia, and 16% to the Institute for Safe Medication Practices.

In an effort to address the emotional needs of pharmacists who were involved in serious medication errors, ASHP unveiled an alliance with the American Psychological Association (APA). Through this collaboration, pharmacists will be able to get appropriate counseling in the aftermath of a medication error. An APA referral service (1-800-964-2000) will direct callers to their state's psychological association to receive information about local therapists.

Another dominant theme at the meeting addressed the problem of staff shortages. At a press conference, ASHP officials acknowledged receiving increasing numbers of complaints by its members regarding recruitment. ASHP president Mick Hunt said that the retail chains and the pharmaceutical industry in particular are luring experienced clinical pharmacists away from health systems with huge salaries and other perks.

In other news, ASHP unveiled eBookMan, a personal digital assistant (PDA) that contains the complete contents of the American Hospital Formulary Service Drug Information resource. The PDA will allow users to record voice messages and keep a calendar and an address book.

And, with an eye to obtaining federal recognition of pharmacists as health-care providers who can bill for professional services, ASHP announced a new coalition with the American College of Clinical Pharmacy. ASHP government affairs officials said that the initiative is a high priority going into 2001.

Anthony Vecchione

Tony Vecchione. Medication errors, staff shortages top list of hot topics at ASHP meeting.

Drug Topics

2001;1:29.