Medication Errors and HIV

Medication errors injure thousands of patients annually, and while mistakes occur with all medication classes, those involving antiretroviral therapies are particularly troublesome.

More than 1 million individuals aged 13 years or older are living with HIV in the United States, with a higher concentration living in urban clusters. The large number of regimen medications, co-morbidities, and dosing schedules used to treat HIV put those taking antiretrovirals at elevated risk for medication errors.

Past studies have suggested that errors are driven by prescribers’ lack of familiarity about antiretrovirals, patients’ ignorance about their complete regimens, and low patient health literacy.

Antiretroviral stewardship, which involves educating prescribers and patients and reviewing orders prospectively, helps increase the use of evidence-based medication regimens. A team of researchers addressed the impact of such stewardship on medication errors in a new study published in the February 2016 issue of Pharmacotherapy.

The researchers assessed antiretroviral stewardship’s impact during 6-month periods over 3 years at Rutgers University Hospital.

In the first year, the researchers measured the baseline medication error rate. The second year coincided with prescriber and pharmacist education and computerized provider order entry system introduction. The third year included prospective order audits with feedback to providers.

The researchers made the following 3 key findings:

1. Medication error rates for patients admitted in the first year were high, but decreased over the 3-year period.

Despite the fact that prescribers in the study were highly experienced and expected to be knowledgeable about antiretrovirals, the initial error rate was unacceptably high. It took months to see significant reductions in error rates.

Of the 334 patients who were admitted in the first year, 45% experienced at least 1 error related to their antiretroviral medication, and 38% had uncorrected errors at the time of discharge. Over the entire 3-year period, however, the medication error rate dropped from 45% to 36% before leveling out at 37%.

The uncorrected error rate at discharge dropped more significantly from 38% to 31% and finally 12%.

2. Half of the errors occurred in the first 24 hours after admission, especially during late-night and weekend hours when formal consults were unavailable.

The researchers said that ideally, an error rate of zero is the goal. However, many patients are admitted after-hours, and unless staffing is enhanced to give every patient access to pharmacist review at admission, that goal may be out of reach.

3. Incorrect dosing was the most common error, followed by inappropriate use of proton pump inhibitors or histamine-2 receptor antagonists with atazanavir (Reyataz) or rilpivirine (Edurant).

The study authors noted that their study demonstrated that setting up a computerized provider order entry system often introduces new errors. (In this case, it did not screen for these 2 drug interactions). Institutions need to customize their systems carefully in order to prevent such errors.

Based on their findings, the study authors recommended initiating an antiretroviral stewardship team that includes infections disease-trained medical and pharmacy staff, as well as increasing staffing to review medications during late-night and weekend hours.

They reported that health care systems can further minimize medication errors by triggering an automatic consult request when HIV diagnostic codes are added, or introducing a “hard stop” signaling an infectious disease or stewardship consult.