Strategies to Prevent Medication Errors  Return to the Beginning

A solid body of evidence points to medication error as a significant source of preventable error in hospitals. A number of organizations have set forth guidelines aimed at preventing drug errors. These include the National Safety Partnership, the Massachusetts Coalition for the Prevention of Medical Errors, the Institute for Healthcare Improvement, the National Coordinating Council for Medication Error Reporting and Prevention, and the American Society for Health-System Pharmacists. Their recommendations are summarized in Appendix A.

Because many of the strategies overlap, and because many medication errors are preventable, the IoM committee identified drug safety as a high priority for all health care organizations. It also outlined selected strategies for improving medication safety. Many of the strategies are designed to help streamline and coordinate some of the complexity that exists within the U.S. health care system, as the risk of errors rising with increasing complexity. The various sources of complexity include the comprehensive knowledge needed to prescribe a sound drug regimen for a patient; the ever-increasing number of medications available and the risk of mixing them up; and the multiple tasks performed by nurses.

The following summarizes the IoM recommendations for enhancing medication safety:

 Adopt a System-Oriented Approach to Medication Error Reduction. Rather than waiting for mistakes to happen, the IoM advises that health-care providers design systems in a manner that anticipates problems. This can be done by altering staffing procedures, adopting new technologies, tracking and analyzing errors and "near misses," and using knowledge gained from past mistakes to establish new systems that help prevent them from occurring in the future.

 Implement Standard Processes for Medication Doses, Dose Timing, and Dose Scales in a Given Patient Care Unit. Standardizing processes is one of the most effective ways to prevent errors. Health care providers can flag potential problems when administering drugs if they are used to dealing with standard doses, times, and scales. This simplifies the process of checking and cross-checking them with other members of the health care team.

 Standardize Prescription Writing and Prescribing Rules. Abbreviations, use of the easily misread letter "q" and "u" can all lead to prescription errors. Standard rules for prescription writing as well as use of computerized order-entry forms can go a long way in preventing errors due to unclear prescriptions. See Appendix I for the recommendations for prescription writing issued by the National Coordinating Council for Medication Error Reporting and Prevention. See Appendix C for the group's recommendations for verbal orders.

 Limit the Number of Different Kinds of Common Equipment. Reducing the number of equipment options is one of the most effective means of reducing medication errors. A single patient care unit should have all the same kinds of equipment such as infusion pumps and defibrillators, so that staff needs only learn and remember one method of setup and operation.

 Implement Physician Order Entry. Computerized order entry systems can prevent medication errors at all stages of the process of administering drugs. It prevents confusion due to illegible handwriting, and it helps ensure that dose, form, and timing are accurate. Computer systems can also double-check for drug-drug or drug-allergy interactions as well as check a patient's vital signs to ensure that a drug will be tolerated. Computerized physician order entry has been recommended by the National Patient Safety Partnership, a coalition of more than a dozen health care organizations including the American Nurses Association, the American Medical Association, the Food and Drug Administration, and the Joint Commission on the Accreditation of Healthcare Organizations.

 Use Pharmaceutical Software. Reliable computer software programs should be used by pharmacies on all health care organizations. At the very least, these programs should screen for duplicate prescriptions, patient allergies, drug-drug interactions, inappropriate doses (based on a patient's weight and age), route of administration, and drug-lab interactions.

 Implement unit dosing. Medications should be purchased in single-doses packaged by the manufacturer, or they should be packaged into single doses at the central pharmacy. Unit dosing reduces the amount of handling of a drug, thereby reducing the need to make calculations, measurements, and preparation - all sources of potential errors on nursing units.

 Have the central pharmacy supply high-risk intravenous medications. Instead of having nurses prepare high-risk IV solutions in patient care units - where the opportunities for mix-ups and miscalculations can be high - the pharmacy should prepare the solutions or buy them already mixed. According to one study, the error rate is 20 percent when IV drugs are mixed by nurses, 9 percent when mixed by central pharmacies, and 0.3 percent when mixed by manufacturers.

 Use special procedures and written protocols for the use of high-risk medications. Drugs with the potential to cause death or serious harm when administered in the wrong dose should be handled with special care. These drugs include heparin, warfarin, insulin, lidocaine, magnesium, muscle relaxants, chemotherapeutic agents, potassium chloride, dextrose injections, narcotics, adrenergic agents, theophylline, and immunoglobin. Such high-risk drugs should be handled using computerized guidelines, checklists, preprinted orders, double-checks, special packaging, and labeling.

 Do not store concentrated potassium chloride solutions on patient care units. Although widely stored on patient care units in concentrated forms, potassium chloride is never intentionally administered in an undiluted form, as it is the most potentially lethal chemicals used in health care. Each year patients die from injections of the drug that hadn't been diluted properly or had been confused with another drug. To prevent this tragic source of error, the pharmacy should dilute potassium chloride, and it should only be stored on patient care units in this diluted form.

 Ensure the availability of pharmaceutical decision support. It is virtually impossible for nurses and physicians to keep up with all the medications on the market. To assist with safe prescribing, pharmacists should be involved with medication administration whenever possible. All hospitals should have access to pharmaceutical decision support, and all organizational systems for dispensing drugs should be designed and approved by pharmacists.

 Include a pharmacist during rounds of patient care units. Pharmacists are an invaluable asset to the health care team when they are present for rounds, when drug decisions are being made and prescriptions are being written. In one study conducted at Massachusetts General Hospital, researchers found that adding a pharmacist to a team of doctors making rounds in an intensive care unit cut medication problems resulting from prescribing errors by 66 percent.

 Make relevant patient information available at the point of patient care. Hospitals can use a number of strategies to prevent patient mix-ups. One is to place color-coded wrist bands on patients with allergies (the color of the band would indicate a particular allergy). Another is to put supermarket-style bar coding on patient wrist bands to reduce mistakes resulting from patient mix-ups. Using a hand-held device, a nurse can swipe both codes to be sure that the right drug gets to the patient for which it is intended.

 Improve patients' knowledge about their treatment. Patients have a right to know what kind of medication they are receiving, its potential side effects, what it looks like, and how often they should receive it. They should also be involved in confirming allergies, current medication regimens, and previous adverse drug experiences. Table 2 gives guidelines health care providers can share with patients to help them ensure their own safety.

[Table 2]
Table 2. 15 Ways Patients Can Help Protect Themselves Against Drug Errors

The person taking or receiving a drug is the last line of defense against drug errors. Whenever patients receive a drug, they should be encouraged to obtain as much information as possible, in consumer-friendly language, both written and oral. Here are some ways patients can protect themselves. (Note that the following tips are geared to patients.)

In the Doctor's Office and Drug Store...

1. Make sure you can read the prescription and directions for use. If anything is illegible, ask the prescriber to re-write or type it.

2. Ask the doctor, pharmacist, or nurse the following questions:

     What are the brand and generic names of this drug?
     What is it supposed to do?
     How should I take it? By mouth, on the skin, in the eye or ear, or some other way?
     How much should I take?
     How many times a day should I take the drug, and for how long?
     Should I take it with meals?
     What should I do if I miss a dose?
     When should I expect the drug to start working?
     How will I know if it is working?
     What should I do if the medicine doesn't seem to work?
     What side effects should I watch for? How long will they last? What should I do if they occur? How can I lessen them?
     While using this drug, should I avoid driving, drinking alcohol, eating certain foods, or taking certain medications? Are there any other precautions or special instructions I should know about?
     How should I store this drug?
     Can I get a refill? If so, when?

3.Take the drug out of the bag and read the label carefully before leaving the pharmacy. Be sure this is the drug the doctor prescribed and that the directions are consistent with what the prescriber told you. If not, tell the pharmacist and go over everything.

4.Ask the pharmacist for a patient information brochure about the drug. In addition, it doesn't hurt to buy a drug information book, particularly one with color pictures, to use as a resource.

5.When you get a refill, open the package or bottle and make sure the drug is the same color, shape, size, and dosage as your original prescription. Note that generic drugs may look different than brand name products. If you notice any inconsistencies, tell the pharmacist.

6.Keep a log of your drugs. Note the names of the medications as well as what they look like. Update your list if any changes occur when you get a refill.

7.Ask for extra help if you have trouble with your vision. Ask your pharmacist to put different drugs in different sizes or types of containers to help you keep distinguish each one.

In the hospital...

1.Know your facility. If possible, find out what kind of checks and balances the hospital uses to prevent medication errors. Find out, for example, whether doctors order drugs by computer. The more safety systems a facility uses, the better.

2.Know what to expect. If you're planning to receive chemotherapy, for example, ask your doctor to write down the regimen that will be given to you before you go the hospital. That way, you'll be better able to question anything that isn't consistent with your plan.

3.Bring a list of all the medications you are taking and have taken. If there's no time to pull together a list, bring the drugs in their containers.

4.Know your current weight. Doses of many medications are based on your weight. Don't rely on estimates of your weight or a measurement taken weeks or months ago. Get an up-to-date reading from a scale.

5.Tell the staff that you're on their team. Many people hesitate to ask questions for fear of putting doctors and nurses on the defense, taking up too much of their time, or being labeled a 'difficult' patient. Set a positive tone up front by telling the staff how you'd like to be treated. Let them know that you want to participate in your care, and that you like to ask questions.

6.Identify yourself. Each time someone comes to give you medication -- be it in an IV solution, injection, or by mouth -- make sure he or she states your name or checks your wrist identification band. If not, state your name. Wearing a name badge also helps. It's also a good idea to remind staff of any allergies.

7.Speak up. Anytime you're given a drug, ask what it is and what it is for. If it looks like the wrong shape, size, or color, say so. Ring the nursing station if it's time for your medication and no one comes by. If you're having trouble getting answers to your questions about your medications, ask to speak with the hospital's patient advocate, such as an ombudsman, nurse manager, or patient representative. Also, ask a friend or family member to act as your advocate if you think you may be feeling too ill to keep track of your medications.

8.Stay 'plugged in.' Patients often ask the staff to disconnect noisy monitors and other machinery if they're feeling better, or if a family member is keeping vigil. But those alarms are almost always there for a reason. The right machines can detect subtle changes in heart rate and other bodily functions that might be the first signs of a medication overdose or drug-drug interaction.

 

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