Appendix E
National Coordinating Council for Medication Error Reporting and Prevention Recommendations for Avoiding Error-Prone Aspects of Dispensing Medications
1. The Council recommends that prescriptions/orders always be reviewed by a pharmacist prior to dispensing. Any orders that are incomplete, illegible, or of any other concern should be clarified using an established process of resolving questions.
2. The Council recommends that patient profiles be current and contain adequate information that allows the pharmacist to assess the appropriateness of a prescription/order.
3. The Council recommends design of the dispensing area to prevent errors. Design should address fatigue-reducing environmental conditions (e.g., lighting, air conditioning, noise level, ergonomic fixtures); minimize distractions (e.g., telephone and personnel interruptions, clutter, unrelated tasks); and provide sufficient resources for workload.
4. The Council recommends that product inventory be arranged to help differentiate medications from one another. This may include use of visual discriminators such as signs or markers. This is particularly important when confusion exists between or among strengths, similar looking labels, and similar sounding names.
5. The Council recommends that a series of checks be established to assess the accuracy of the dispensing process prior to the medication being provided to the patient. Whenever possible, an independent check by a second individual should be used. Other methods of checking include the use of automation, computer systems, and patient profiles.
6. The Council recommends that labels be read at least three times, for example, when selecting the product, when packaging the product, and when returning the product to the shelf.
7. The Council recommends that pharmacists counsel patients. Counseling should be viewed as an opportunity to verify the accuracy of dispensing and the patient's understanding of proper medication use.
8. The Council recommends that pharmacies collect data regarding actual and potential errors for the purpose of continuous quality improvement.
Source: Copyright 1998 – 2002 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.
Appendix F
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.
Source: Copyright 1998 – 2002 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved.
