May 11, 2014
WRIGHT-PATTERSON AIR FORCE BASE – Air Force officials have concluded the investigation of prescription medication errors dispensed to patients at the Wright-Patterson Medical Center and determined the risk to the patient population was very small.
An exhaustive review conducted by experts from the 88th Medical Group discovered no reports or findings of patients actually taking the wrong medications. According to officials, the majority of the medications brought in by patients and screened by the staff have been found to be accurate, with the exception of the eight instances of Tylenol being mixed into refills of Robaxin.
The reviewers found no incidents of harm to any patients.
Officials cited the quick response by the Kittyhawk Pharmacy staff as key reasons the issue was caught early and patient harm was prevented. They also noted information from this investigation will be used to make improvements throughout the DoD Medical Service.
“We want to thank our patients and the media for partnering with us during the course of this event,” Col. Cassie Barlow, 88th Air Base Wing commander said. “This problem was found because one of our patients chose to take an active role in their health care by speaking up when they identified something that did not seem right. We encourage all of our patients to do this, and owe this patient a debt of gratitude for helping us to ensure that this event did not cause harm to our beneficiaries.”
All equipment, medications, maintenance processes and all records of patients affected by this incident were scrutinized. The 88th Medical Group experts focused on analyzing the facts and the machinery and its maintenance, along with actual and potential risk to patients.
In addition, a separate quality analysis by a team from the Air Force Medical Operations Agency (AFMOA) was conducted to determine what happened, why it happened, who was affected, whether there is continued risk and, if so, how the risk can be mitigated. To answer these questions the AFMOA team examined all processes, procedures, human factors, and contributing factors that may have caused the medications to become mixed.
The review results focused on improvement in processes and procedures for maintaining and interacting with the robot, an automated dispensing system, officials said. Due to an extraordinary amount of workflow through the Kittyhawk Pharmacy, the review recommended the center build more opportunities for control structures into daily operating procedures, to include more robust mechanisms in place for communicating updated recommendations for maintaining the machine at an optimal level of performance. The review found that timely and efficient maintenance of this complex machinery is critical to its proper performance and corrective action was identified to prevent future mishaps.
The analysis of the robot has determined that it is functioning properly and, after rigorous test runs and quality checks, will be re-started. A review of similar machinery in other Air Force Medical Treatment Facilities did not reveal any problems similar to the one here, but improved maintenance programs will be initiated for those as well in a pro-active effort of incident prevention.
Finally, the review process assisted in developing a mitigation and response plan to better improve communication between the manufacturer and the hospital.
All recommendations for corrective actions were immediately adopted and implemented according to Medical Center officials.
While the review has concluded, pharmacy personnel stated they are continuing to review medications for any concerned patients. As of this time, 926 of the 1,273 patients identified as being at risk have been cleared by walk-in, telephone contact, or because they had not yet picked up their medications. Signs are located in the hospital atrium directing patients to where they should go for prescription review.
Officials did confirm the hotline will be discontinued; however, ongoing efforts will be made to notify patients who have not been contacted. Additionally, the hospital staff remains available to answer patient questions and respond to their needs. Patients may contact their Primary Care clinic or walk in to the pharmacy area if they have further questions.