Medication, avoiding errors

The Council recommends the development of policies and procedures for repaekaging of medications that will clarify labeling to help avoid errors. 

Riskprevention/mModijication. Pharmacy managers may not be able to eliminate a risk, but they can take steps to minimize the likelihood of its occurrence. All pharmacies take steps to avoid medication dispensing errors. This commonly involves the development of policies and procedures to prevent errors and improve patient safety (see Chapters 7 and 30). 

Recommendations for avoiding error-prone aspects of dispensing medications, USP Qual. Rev., June 1999, No. 67. 

Avoidance of medication administration errors is another potential contribution of critical care pharmacists. A multicenter analysis of medication errors from five ICUs revealed that medication errors occurred most commonly with vasoactive agents and sedative-analgesics. " Incorrect infusion rate was the most common error. The overall... 

Be sure that the list of medications a client is taking is updated. If it cannot be easily tracked in the client s record, other ways of providing this information should be instituted. For example, the social worker can help the client to create an index card that lists current and past medications. The client should have the card available for review at every appointment with a health care provider. Be sure that all medications are listed including the name, dose, number, and date of last refill. By ensuring that all providers are aware of what a client is taking, problems with duplicate prescriptions, drug interactions and side effects, contraindicated medications, and errors in dosages can be avoided. 

Cutler, T.W. Medication reconciliation victory after an avoidable error. WebM M, February/March 2009. 

Cutler, T.W. Medication Reconciliation Victory after an Avoidable Error, AHRQ Web M M, Eebruary/March 2009. 

Medication error information submitted to USP is entered into a nationally recognized repository for medication error reporting. This database serves to track, monitor, and analyze medication errors from a systems-based perspective. The USP develops educational resources and materials to disseminate best practice solutions and error-avoidance strategies to students and practitioners. 

The ability to prediet error and thus avoid it is the focus of the scienee of human faetors engineering. The adaptation of this seienee to the medication use process can help to prediet the ehanees that a medieation error will ocem. Pharmaeeutical manufaeturers should design produets ineluding their names, labeling, and paekaging so that errors ean be avoided and systems and health eare delivery will be safer. 

We support the intelligent choice of medications based on rational reasons, but avoid the position that all medication is bad, serving only as a substitute for adequate staffing. In this context, there is a great deal of trial and error in dosage adjustment, and there is no substitute for close monitoring in conjunction with frequent feedback from nursing staff. 

The instructions on how and when to take medications, the duration of therapy, and the purpose of the medication must be explained to each patient by the physician and by the pharmacist. (Neither should assume that the other will do it.) Furthermore, the drug name, the purpose for which it is given, and the duration of therapy should be written on each label so that the drug may be identified easily in case of overdose. An instruction to "take as directed" may save the time it takes to write the orders out but often leads to noncompliance, patient confusion, and medication error. The directions for use must be clear and concise to avoid toxicity and to obtain the greatest benefits from therapy. 

Cohen MR, Senders J, Davis NM. 1994. Failure mode and effects analysis A novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm 29 319. 

Errors can result when ambiguous orders are interpreted in a manner other than what the prescriber intended. Proper expression of doses is vital in a drug order. Pharmacists should be able to recognize improper expressions of doses, and the potential for error, when they see them. When the order is not clear, the pharmacist must contact the prescriber for clarification. Pharmacists and technicians should avoid using dangerous expressions of doses as they process orders, type labels, and communicate with others. The following examples include several improperly expressed orders that were reported to the Institute for Safe Medication Practices (ISMP) ... 

This application was unique and accepted by an industry that was determined to avoid any errors in data transfer, as would be the case if alternate data transcription were used. It appeared to me that other medical applications could have benefited from this approach and I frequently, without success, tried to promote extending the market. No one was particularly interested—the aca people had their hands full with solving their internal problems, and no one was available to promote the paper as a unique product. 

Periodically train staffs in practices that will help avoid medication errors. 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while medication is in the control of a healthcare professional/ patient/ or consumer (6). Not all medication errors reach the patient. These are often referred to as "near misses." They are not usually considered to be ADEs only because no harm was done. Preventable ADEs are a subset of medication errors that cause harm to a patient (7). Figure 26.1 depicts the relationship between ADES/ medication errorS/ and adverse drug reactions (8). Because adverse drug reactions are generally unexpected/ they are not presently considered to be a reflection of medication use quality in a classic sense. However/ as genetic variances become a more prominent consideration in drug selection and monitoring/ it may be possible to predict and avoid some of the reactions that have been previously unexpected. This offers an opportunity to improve the quality of medication use. 

The medication use process is a complex system intended to optimize patient outcomes within organizational constraints. Quality medication use involves selection of the optimal drug, avoidance of adverse medication events, and completion of the therapeutic objective. Safe medication practices focus on the avoidance of medication errors. Medication use review and ongoing medication monitoring activities focus on optimizing medication selection and use. These two approaches are important means of assessing and optimizing the quality of medication use. 

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