Analysis of Intervention Employability in Pharmacy-Related Medication Safety Reports at a Tertiary Medical Center

Background: The Institute for Safe Medication Practice (ISMP) suggests that patient safety reports be addressed with systematic, fail-safe, actions to prevent error recurrence. ISMP’s hierarchy of effectiveness of risk reduction strategies places education-related interventions as the least effective and fail-safes at the top. UNM Hospitals creates a positive environment for safety reporting, but often we are limited to education interventions due to resource and technology constraints. This study analyzes the intervention potential and quality of pharmacy-related medication safety reports. Methods: One thousand medication-related safety reports from selected time points between 2012 and 2022 were selected. Safety reports were included in our study if they were actionable by the pharmacy department. Each safety report was categorized by type of safety event and given an intervention potential score of 1 to 10 (1 indicating education-only, 10 being forcing function) by 2 student pharmacists and 1 pharmacy director based on their potential place on ISMP’s hierarchy. Safety report quality was graded based on professionalism, organization, clarity, and completeness. A standardized evaluation form was used for evaluation for all elements. Results: Six-hundred-sixty-five safety reports were pharmacy-related and evaluated by all 3 study team members for analysis. The 3 most common pharmacy-related safety reports were medication delivery, inappropriate order verification, and transcribing errors which accounted for over half of the reports (59.5%) and on average the intervention potential score of these types of safety reports was education only. Overall, safety reports were limited to a maximum actionability of education-only 75.4% of the time. Safety reports were found to be professionally written and well organized. Conclusion: The actionability of most pharmacy-related medication safety reports was limited to low leverage interventions likely because high leverage solutions were addressed with systematic change and did not recur. Errors limited to education interventions repeated and this increased relative counts of low leverage actionability of safety reports. The ISMP hierarchy of effectiveness of risk-reduction strategies is an important guide to intervening in medication-related safety events, but pharmacy staff should not be discouraged if most of the safety reports cannot be addressed through high-leverage interventions.