Strategies to Prevent Medication Errors

A solid body of evidence points to medication error as a significant source of preventable error in hospitals. A number of organizations have published prevention strategies for reducing medication errors in hospitals. These include the Agency for Healthcare Research and Quality, the American Society of Health-System Pharmacists, the Institute for Healthcare Improvement, the Institute of Medicine, the Institute for Safe Medication Practices, the Joint Commission on Accreditation of Healthcare Organizations, the Massachusetts Coalition for the Prevention of Medical Errors, the National Quality Forum, the National Coordinating Council for Medication Error Reporting and Prevention, Pathways for Medication Safety, and the US Pharmacopeia.

The following summarizes the organizations' recommendations for prevention of medication errors:

• Adopt a systems-oriented approach to medication error reduction. Rather than waiting for mistakes to happen, the IoM and other organizations advise 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.
• Use improved communication practices, such as always resolving medication discrepancies prior to administration.
• Take steps to reduce workplace fatigue, such as planned naps, careful scheduling, or light therapy.
• Create a culture of safety.
• Collect the medication history, and reconcile the list with the patient and other providers during care transitions.
• Improve the work environment for medication preparation, dispensing, and administration.
• Improve error detection and reporting, and promote a nonpunitive atmosphere.
• Use failure modes and effects analysis or other strategies for risk management.
• 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 crosschecking them with other members of the health care team.
• Use automated medication dispensing devices.
• Implement bar coding technology at the point of care. Hospitals can put supermarket-style bar coding on patient wristbands 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.
• Standardize prescription writing and prescription rules, and eliminate certain abbreviations and dose expressions. Abbreviations and 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.
• 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 computerized provider order entry. Computerized order entry systems can prevent medication errors at all stages of the process of administering drugs. They prevent confusion due to illegible handwriting, and they help 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.
• Use pharmaceutical software. Reliable computer software programs should be used by pharmacies in 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.
• Limit informally structured verbal communication of medication prescriptions.
• Monitor for look-alike and sound-alike medications.
• Institute policies and procedures regarding labeling of all medications.
• Establish a controlled formulary in which the selected medications are based more on safety than on cost.
• Have the central pharmacy supply high-risk intravenous medications and pharmacy-based admixture systems. 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.
• Employ special procedures and written protocols for the use of high-risk IV and oral 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 solutions of hazardous medications on patient care units, and limit the number of drug concentrations available in the organization. Although widely stored on patient care units in concentrated forms, potassium chloride, for example, is never intentionally administered in an undiluted form. It is one of 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 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.
• Utilize pharmacist counseling of patients.
• Have a pharmacist available on call after hours of pharmacy operation.
• Have a pharmacist review all medication orders before first doses.
• 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 wristbands on patients with allergies (the color of the band would indicate a particular allergy). Another is to put supermarket-style bar coding on patient wristbands 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.

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.)

Return to the Beginning