Appendix G Return to the Beginning

National Coordinating Council for Medication Error Reporting and Prevention Recommendations to Reduce Errors Related to Administration of Drugs

1.The Council recommends that any order that is incomplete, illegible, or of any other concern should be clarified prior to administration using an established process for resolving questions.

2.The Council recommends that as one aspect of the overall medication use system, the following checks be performed immediately prior to medication administration: the right medication, in the right dose, to the right person, by the right route, at the right time.

3.The Council recommends that users of medication administration devices be knowledgeable about the device function and limitations.

4.The Council recommends that when electronic infusion control devices are employed, only those that prevent free-flow upon removal of the administration set should be used.

5.The Council encourages the use of linked automated systems (e.g., direct order entry, computerized medication administration record, bar coding) to facilitate review of prescriptions, increase the accuracy of administration, and reduce transcription errors.

6.The Council recommends that all persons who administer medications have adequate access to patient information, as close to the point of use as possible, including medical history, known allergies, prognosis, and treatment plan, to assess the appropriateness of administering the medication.

7.The Council recommends that all persons who administer medications have easily accessible product information as close to the point of use as possible, and are:

knowledgeable about indications for use of the medication as well as precautions and contraindications;
knowledgeable of the expected outcome from its use;
knowledgeable about potential adverse reactions and interactions with food or other medication;
knowledgeable of actions to take when adverse reactions or interactions occur; and
knowledgeable about storage requirements.

8.The Council recommends that health care professionals administer only medications that are properly labeled and that during the administration process, labels be read three times: when reaching for or preparing the medication, immediately prior to administering the medication, and when discarding the container or replacing it into its storage location.

9.The Council recommends that at the time of administration, the name, purpose and effects of the medication be discussed with the patient and/or caregiver.

10.The Council recommends ongoing patient monitoring for desired and/or expected medication effects.

11.The Council recommends that the role of the work environment be considered when assessing safety of the drug administration process. Factors such as lighting, temperature control, noise-level, occurrence of distractions (e.g., telephone and personal interruptions, performance of unrelated tasks, etc.) should be examined. Sufficient resources must be provided for the given workload. The science of ergonomics should be employed in the design of safe systems.

12.The Council recommends that data be collected regarding the actual and potential errors of administration for the purpose of continuous quality improvement.

Appendix I

National Coordinating Council for Medication Error Reporting and Prevention Recommendations to Correct Error-Prone Aspects of Prescription Writing

All prescription documents must be legible. Prescribers should move to a direct, computerized, order entry system.

Prescription orders should include a brief notation of purpose (e.g. for cough), unless considered inappropriate by the prescriber. Notation of purpose can help further assure that the proper medication is dispensed and creates an extra safety check in the process of prescribing and dispensing a medication. The Council does recognize, however, that certain medications and disease states may warrant maintaining confidentiality.

All prescription orders should be written in the metric system except for therapies that use standard units such as insulin, vitamins, etc. Units should be spelled out rather than writing "U." The change to use of the metric system from the archaic apothecary and avoirdupois systems will help avoid misinterpretations of these abbreviations and symbols, and miscalculations when converting to metric, which is used in product labeling and package inserts.

Prescribers should include age, and when appropriate, weight of the patient on the prescription or medication order. The most common errors in dosage result in pediatric and geriatric populations in which low body weight is common. The age (and weight) of a patient can help dispensing health care professionals in their double check of the appropriate drug and dose.

The medication order should include drug name, exact metric weight or concentration, and dosage form. Strength should be expressed in metric amounts and concentration should be specified. Each order for a medication should be complete. The pharmacist should check with the prescriber if any information is missing or questionable.

A leading zero should always precede a decimal expression of less than one. A terminal or trailing zero should never be used after a decimal. Ten-fold errors in drug strength and dosage have occurred with decimals due to the use of a trailing zero or the absence of a leading zero.

Prescribers should avoid use of abbreviations including those for drug names (e.g., MOM, HCTZ) and Latin directions for use. The abbreviations in the chart below are found to be particularly dangerous because they have been consistently misunderstood and therefore, should never be used. The Council reviewed the uses for many abbreviations and determined that any attempt at standardization of abbreviations would not adequately address the problems of illegibility and misuse.

Dangerous Abbreviations:

Abbreviation	Intended Meaning	Common Error
U	Units	Mistaken as a zero or a four (4) resulting in overdose. Also mistaken for "cc" (cubic centimeters) when poorly written.
μg	Micrograms	Mistaken for "mg" (milligrams) resulting in a ten-fold overdose.
Q.D.	Latin abbreviation for every day	The period after the "Q" has sometimes been mistaken for an "I," and the drug has been given "QID" (four times daily) rather than daily.
Q.O.D.	Latin abbreviation for every other day	Misinterpreted as "QD" (daily) or "QID" (four times daily). If the "O" is poorly written, it looks like a period or "I."
SC or SQ	Subcutaneous	Mistaken as "SL" (sublingual) when poorly written.
T I W	Three times a week	Misinterpreted as "three times a day" or "twice a week."
D/C	Discharge; also discontinue	Patient's medications have been prematurely discontinued when D/C, (intended to mean "discharge") was misinterpreted as "discontinue," because it was followed by a list of drugs.
HS	Half strength	Misinterpreted as the Latin abbreviation "HS" (hour of sleep).
cc	Cubic centimeters	Mistaken as "U" (units) when poorly written.
AU, AS, AD	Latin abbreviation for both ears; left ear; right ear	Misinterpreted as the Latin abbreviation "OU" (both eyes); "OS" (left eye); "OD" (right eye)

Prescribers should not use vague instructions such as "Take as directed" or "Take/Use as needed" as the sole direction for use. Specific directions to the patient are useful to help reinforce proper medication use, particularly if the therapy is to be interrupted for a time. Clear directions are a necessity for the dispenser to: (1) check the proper dose for the patient; and, (2) enable effective patient counseling.

Take Post Examination