Prescribing medication errors prevention

The lOM report concludes that most of these errors are the result of systemic problems rather than poor performance by individual providers. Pharmacists play a key role in helping prevent and eliminate medication errors by providing information on the proper use of medications. Pharmacists provide the link between prescribers and patients, as shown in Figure 27.1, and can monitor for medication errors and adverse events. 

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems including prescribing order communication product labeling, packaging, and nomenclature compounding dispensing distribution administration education monitoring and use. 

Reason (21) has described a model for looking at human error that portrays a battle between the sources of error and the system-based defenses against them. This model is often referred to as the "Swiss cheese model" because the defenses against error are displayed as thin layers with holes that are described as latent error in the system. Figure 26.5 demonstrates the model as applied to medication error. Each opportunity for error is defended by the prescriber, pharmacist, nurse, and patient. When a potential error is identified and corrected (e.g., dose error, route of administration error) the event becomes a "near miss" rather than an ADE. In those cases in which the holes in the Swiss cheese line up, a preventable medication error occurs. The Swiss cheese model provides an interesting framework for research in this field. 

Pharmacy refill records can be a valuable source for assessing what the patient is prescribed and how often the patient refills the prescriptions. Clarification of medication usage should be verified by refill records in your practice setting or by contacting pharmacies that the patient uses. Inpatient pharmacists can provide valuable patient information to the outpatient or retail pharmacists upon hospital discharge. This can prevent duplication and medication errors. 

Prescriber Order-Entry Module Common dosage order database of standardized inpatient and outpatient medication orders, ready for integration into providers order-entry or prescription-writing systems helps prevent prescribing errors. 

Prescriber Order Entry Module (POEM ) provides a database of the most common medication orders. These orders are specific to drug, route of administration, formulation, age, indication/use, and weight or body surface area, if applicable. This enables more accurate and efficient point-of-care computerized order entry applications to prevent errors at the prescribing stage of drug delivery. 

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