Perhaps the biggest story of 2013 in the area of pharmacy errors revolved around the fungal meningitis outbreak linked to compounding errors in tainted steroids from the New England Compounding Center that caused hundreds of illnesses and dozens of deaths around the country.
In response, the National Association of Boards of Pharmacy came down on six compounding pharmacies in four states. Meanwhile, the FDA and state pharmacy boards also stepped up inspections and found an abundance of safety violations at compounding pharmacies nationwide. The crisis culminated in Congress’ passage of the Drug Quality and Security Act, aimed at increasing regulation of compounding pharmacies, although the somewhat toothless reforms may not do much in the end to increase public health and safety. Compounding is the process of preparing a particular medication to meet the needs of specific patients who may have allergies to certain ingredients or require their medications in a particular form.
In other news, the latest Medication Self-Assessment Survey issued by the Institute for Safe Medication Practices (ISMP) revealed an average score of 64% on initial and ongoing training on medication use and safe medication practices to prevent medication error. ISMP is the nation’s only nonprofit organization devoted entirely to the prevention of medication errors and the safe use of medication.
Also in 2013, the American Society of Health-System Pharmacists (ASHP) at its Summer Meeting held a session on crisis management to deal with catastrophic medication errors and the fallout in negative media coverage and lawsuits that could follow. Recommendations included having a crisis management team at the ready, including the hospital’s chief public relations officer and legal counsel on the team, among others.