Improving Patient Safety—Improving Lives: A Patient’s Story

Many Americans live with multiple chronic diseases that require them to seek medical care from numerous physicians, primary care clinicians, and health care facilities. Many of these patients are receiving multiple prescription medications from their providers, but not being monitored for drug-drug interactions or adverse drug events. The Institute of Medicine, warning that the safety and quality risk associated with medications is high, reported the following facts:¹

• • Adverse health care events continue to be a leading cause of death and injury.

• • 1.5 million people are injured each year in the U.S. as a result of medication errors.

• • Nearly 25% of ambulatory patients report adverse drug events.

• • As much money as is spent on ambulatory medication is spent on treating new health problems caused by the medication.

As a result of widespread utilization of medications within the United States health care system and a lack of a systematic method of monitoring drug efficacy and adverse drug events, the Health Resources and Services Administration (HRSA) has initiated the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC).

The primary goal of PSPC is to integrate health care delivery systems further by maximizing the use of clinical pharmacy services and safe medication practices that ultimately improve patient outcomes.² It seeks to create patient-centered care for high-risk patients that will produce breakthroughs in the following three areas: 1) improved patient health outcomes; 2) improved patient safety; and 3) increasing cost-effective clinical pharmacy services.

The PSPC was initiated to prevent medicine-related confusion and outcomes such as those experienced by a woman whom we will call Emma Jones. What follows is Emma’s story, in her own words. The Association of Clinicians for the Underserved (ACU) supports the efforts of the PSPC and pharmacists nationwide to keep similar stories from ever taking place.

Paying the Price for a Flawed Health Care System

Long ago, I lost my mother suddenly, apparently as the result of medical errors, poor communication, and a flawed system of health care delivery. Retrospectively, it appears to medical professionals who reviewed her records that she may have died from ingesting toxic levels of potassium in the course of prescribed medication in conjunction with congestive heart failure. During her rapid decline, however, these problems were not identified or treated, while others were (perhaps spuriously).

My mother was a vibrant, healthy woman in her mid-seventies when she and I were involved in an automobile accident. She suffered from severe back pain following the accident and saw multiple providers for her pain. In addition to her primary care provider, she was also seeing an orthopedic doctor, a physical therapist, and a neurologist on a regular basis. One of the doctors prescribed a medication for her back pain and she began to take it daily. She seemed to be herself again when taking this medication; she was unaware that this drug had side effects or that it would elevate her blood sugars. She took the medicine for over a year, not experiencing any problems. Over time, she did develop diabetes, and needed medication for that as well.

Within three weeks of starting the diabetes medication, my mother’s health began to deteriorate rapidly. She was tired all the time and was very short of breath. She suddenly seemed to have put on weight, her ankles and feet were swelling, her vision was blurred, and she easily bruised and developed petichiae all over her arms and other parts of her body. She was also losing her balance and falling. Her doctor recommended using a walker. One day, she fell outside of her town home and hit her head on the cement. The doctor saw her the following day in his office. He did some tests and told her that the diabetes was causing all of these sudden symptoms, and increased the dosage of the diabetes medication.

The pharmacist disagreed with this physician. He was concerned that my mother’s problems might be coming from the diabetes medication rather than from diabetes. Within five weeks, her skin...