Medication safety is a high priority for the health care professional. Prevention of medication errors and improved safety for the pt are important, esp. in today’s health care environment when today’s pt is older and sometimes sicker and the drug therapy regimen can be more sophisticated and complex.
A medication error is defined by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) as “any preventable event that may cause or lead to inappropriate medication use or pt harm while the medication is in the control of the health care professional, pt, or consumer.”
Most medication errors occur as a result of multiple, compounding events as opposed to a single act by a single individual.
Use of the wrong medication, strength, or dose; confusion over sound-alike or look-alike drugs; administration of medications by the wrong route; miscalculations (esp. when used in pediatric pts or when administering medications intravenously); and errors in prescribing and transcription all can contribute to compromising the safety of the pt. The potential for adverse events and medication errors is definitely a reality and is potentially tragic and costly in both human and economic terms.
Health care professionals must take the initiative to create and implement procedures to prevent medication errors from occurring and implement methods to reduce medication errors. The first priority in preventing medication errors is to establish a multidisciplinary team to improve medication use. The goal for this team would be to assess medication safety and implement changes that would make it difficult or impossible for mistakes to occur. Some important criteria in making improved medication safety successful include the following:
• Promote a nonpunitive approach to reducing medication errors.
• Increase the detection and the reporting of medication errors, near misses, and potentially hazardous situations that may result in medication errors.
• Determine root causes of medication errors.
• Educate about the causes of medication errors and ways to prevent these errors.
• Make recommendations to allow organization-wide, system-based changes to prevent medication errors.
• Learn from errors that occur in other organizations and take measures to prevent similar errors.
Some common causes and ways to prevent medication errors and improve safety include the following:
Handwriting: Poor handwriting can make it difficult to distinguish between two medications with similar names. Also, many drug names sound similar, esp. when the names are spoken over the telephone, poorly enunciated, or mispronounced.
• Keep phone or verbal orders to a minimum to prevent misinterpretation.
• Repeat back orders taken over the telephone.
• When ordering a new or rarely used medication, print the name.
• Always specify the drug strength, even if only one strength exists.
• Express dosages for oral liquids only in metric weights or volumes (e.g., mg or ml), not by teaspoon or tablespoon.
• Print generic and brand names of look-alike or sound-alike medications.
Zeros and decimal points: Hastily written orders can present problems even if the name of the medication is clear.
• Never leave a decimal point “naked.” Place a zero before a decimal point when the number is less than a whole unit (e.g., use 0.25 mg or 250 mcg, not .25 mg).
• Never have a trailing zero following a decimal point (e.g., use 2 mg, not 2.0 mg).
Abbreviations: Errors can occur because of a failure to standardize abbreviations. Establishing a list of abbreviations that should never be used is recommended.
• Never abbreviate unit as “U”; spell out “unit.”
• Do not abbreviate “once daily” as OD or QD or “every other day” as QOD; spell it out.
• Do not use D/C, as this may be misinterpreted as either discharge or discontinue.
• Do not abbreviate drug names; spell out the generic and/or brand names.
Ambiguous or incomplete orders: These types of orders can cause confusion or misinterpretation of the writer’s intention. Examples include situations when the route of administration, dose, or dosage form has not been specified.
• Do not use slash marks—they may be read as the number one (1).
• When reviewing an unusual order, verify the order with the person writing the order to prevent any misunderstanding.
• Read over orders after writing.
• Encourage that the drug’s indication for use be provided on medication orders.
• Provide complete medication orders—do not use “resume preop” or “continue previous meds.”
• Provide the age and, when appropriate, the weight of the pt.
High-alert medications: Medications in this category have an increased risk of causing significant pt harm when used in error. Mistakes with these medications may or may not be more common but may be more devastating to the pt if an error occurs. A list of high-alert medications can be obtained from the Institute for Safe Medication Practices (ISMP) at www.ismp.org.
Technology available today that can be used to address and help solve potential medication problems or errors includes the following:
• Electronic prescribing systems—This refers to computerized prescriber order entry systems. Within these systems is the capability to incorporate medication safety alerts (e.g., maximum dose alerts, allergy screening). Additionally, these systems should be integrated or interfaced with pharmacy and laboratory systems to provide drug–drug and drug–disease interactions alerts and include clinical order screening capability.
• Bar codes—These systems are designed to use bar-code scanning devices to validate identity of pts, verify medications administered, document administration, and provide safety alerts.
• “Smart” infusion pumps—These pumps allow users to enter drug infusion protocols into a drug library along with predefined dosage limits. If a dosage is outside the limits established, an alarm is sounded and drug delivery is halted, informing the clinician that the dose is outside the recommended range.
• Automated dispensing systems; point-of-use dispensing system—These systems should be integrated with information systems, esp. pharmacy systems.
• Pharmacy order entry system—This should be fully integrated with an electronic prescribing system with the capability of producing medication safety alerts. Additionally, the system should generate a computerized medication administration record (MAR), which would be used by the nursing staff while administering medications.
Medication reconciliation: Medication errors generally occur at transition points in the pt’s care (admission, transfer from one level of care to another [e.g., critical care to general care area], and discharge). Incomplete documentation can account for up to 60% of potential medication errors. Therefore, it becomes necessary to accurately and completely reconcile medication across the continuum of care. This includes the name, dosage, frequency, and route of medication administration.
Medication reconciliation programs are a process of identifying the most accurate list of all medications a pt is taking and using this list to provide correct medications anywhere within the health care system. The focus is on not only compiling a list but using the list to reduce medication errors and provide quality pt care.
Additional Strategies to Reduce Medication Errors
The ISMP, FDA, and other agencies have identified high-risk areas associated with medication errors. They include the following:
At-risk population: At-risk populations primarily include pediatric and geriatric pts. For both, this risk is due to altered pharmacokinetic parameters with little published information regarding medication use in these groups. Additionally, in the pediatric population, the risk is due to the need for calculating doses based on age and weight, lack of available dosage forms, and concentrations for smaller children.
In a USP report, more than one-third of medication errors reaching the pt occurred in pts 65 yrs of age and older. Almost 40% of people 60 yrs and older take at least five medications. More than 50% of fatal hospital medication errors involve seniors. In the senior population, age-related physiologic changes (e.g., decreased renal function, reduced muscle mass) increase the risk for adverse events.
Avoid abbreviations and nomenclature: The confusion caused by abbreviations has prompted the ISMP to develop a list of abbreviations that should be avoided (see back cover of handbook).
Recognize prescription look-alike and sound-alike medications: The ISMP has developed an extensive list of confused drug names (see www.jointcommission.org). See individual monographs for DO NOT CONFUSE information.
Focus on high alert medications: High alert medications are medications that bear a heightened risk of causing significant pt harm if incorrectly used. High alert medications in the handbook have a colored background for the entire monograph.
Look for duplicate therapies and interactions: Drug interactions and duplicate therapies can increase risk of adverse reactions. Refer to individual monographs for significant interaction information (drug, herbal, food).
Report errors to improve process: This action plays an important role in preventing further errors. The intent is to identify system failures that can be altered to prevent further errors.