ARV Medication Errors: Experience of a Community-Based HIV Specialty Clinic and Review of the Literature

Abstract

Objective To describe antiretroviral (ARV) medication errors reported within a community Human Immunodeficiency Virus (HIV) clinic, identify potential strategies to prevent errors, and review the literature pertaining to ARV medication errors. Design Review of voluntarily reported ARV errors. Errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) Index. The clinic's medication distribution process was also analyzed. Setting Community-based clinic with HIV-experienced clinicians in an urban setting. Results Thirty-seven errors were reported over 3 years; 81.1% of these were classified as NCC-MERP category C. Most errors resulted from lapses in clinic and pharmacy systems of care (n = 21). Pharmacy and clinic prescribing errors were less (n = 11). Conclusion ARV medication errors were notable. Changes in drug distribution and prescribing processes may reduce future ARV medication errors.

Implementation of targeted interventions to decrease antiretroviral-related errors in hospitalized patients

“…14–22 Prior studies in hospitalized patients with HIV have reported error rates between 5% and 30%. 15–18 Medication errors of omission could potentially have deleterious consequences for the long term care of patients with HIV through the development of resistance mutations rendering current available drug regimens ineffective.…”

Improved antiretroviral refill adherence in HIV-focused community pharmacies

“…HIV+ patients are at higher risk for medication errors, duplicate therapy, and non-adherence due to HIV medications not being stocked and the inconvenience of making multiple trips to the pharmacy to procure a complete regimen. [3–6] To ameliorate these issues, some community pharmacies now provide longitudinal HIV medication therapy management (MTM) services at designated locations. [7–9] …”