Reducing Medication Errors

Failure to administer medication when required or as prescribed Administration of the medication at the wrong time or using an incorrect route Administration of the wrong dosage or concentration of a drug Administration of the wrong medication 

Misunderstanding verbal/written medication orders including transcription 

Failure to read container labels and using improper injection techniques 

Discourage the use of verbal and telephone orders. Implement a verification process for verbal or telephone orders. Create policies for implementing weight-based dosing. 

---

Box 7.1 Starting point for reducing medication errors in hospitals... 

QulC, Report of the Quality Interagency Coordination Task Force (QulC) to the President. Doing What Counts for Patient Safety Federal Actions to Reduce Medical Errors and Their Impact, February 2000, Rockville, MD (http //www.quic.gov/report). 

Cincinnati Children s Hospital Medical Center, the 2003 recipient of the prestigious Healthcare Information Management and Systems Society s (HIMSS) Nicholas E. Davies Award of Excellence for Electronic Health Record (eHR), was able to reduce medication errors by 35% and decrease medication turnaround time by 52% through the use of an integrated clinical information system. 

A hospital trolley developed by Bayer and GMP is described. The trolley is equipped with a portable computer for the collection and management of patient information with the aim of reducing medical errors. The main component is a sandwich stracture reaction injection monlded in Bayer s Baydnr 60 PU and consisting of a cellnlar core and a smooth skin. Other components are made of PP, PMMA or polycarbonate. Developments by GMP in the nse of PU foams in refrigerator manufacture are also reviewed, and tnmover fignres are presented for the Company. 

Strategies to Reduce Medication Errors Working to Improve Medication Safety... 

In addition, the U.S. Department of Health and Human Services (HHS) and other federal agencies formed the Quality Interagency Coordination Task Force in 2000 and issued an action plan for reducing medical errors. In 2001, former HHS Secretary Tommy G. Thompson announced a Patient Safety Task Force to coordinate a joint effort to improve data collection on patient safety. The lead agencies are the FDA, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality. 

The FDA enhanced its efforts to reduce medication errors by dedicating more resources to drug safety, which included forming a new division on medication errors at the agency in 2002. FDA works to prevent medication errors before a drug reaches the market and monitors any errors that may occur after that, says Jerry Phillips, R.Ph., former director of the FDA s Division of Medication Errors and Technical Support. 

Here s a look at key areas in which the FDA is working to reduce medication errors. 

Hospitals and other health care organizations work to reduce medication errors by using technology, improving processes, zeroing in on errors that cause harm, and building a culture of safety. Here are a couple of examples. 

Computerized Physician Order Entry (CPOE) Studies have shown that CPOE is effective in reducing medication errors. It involves entering medication orders directly into a computer system rather than on paper or verbally. The Institute for Safe Medication Practices conducted a survey of... 

Berman A. Reducing medication errors through naming, labeling, and packaging. / Med Syst. 2004 28 9-29. 

It was reported by the Institute for Safe Medication Practices (ISMP) in 2000 that fewer than 5 percent of physicians were writing prescriptions electronically. In a 2000 white paper entitled, A Call to Action Eliminate Handwritten Prescriptions within 3 Years, ISMP recommended the use of electronic prescribing by clinician order entry to reduce medication errors (ISMP, 2000). CPOE can help to reduce errors in the delivery and transcribing of orders to the pharmacy where the orders are filled. Order management can be used to control inventory and alert pharmacy staff (and even the patient) of the status of a prescription. For example, some national chain pharmacies have the capability of alerting the patient by phone or e-mail if a prescription is ready or if other action needs to be taken before the prescription can be picked up. The system should also be able to report results, such as the number of prescriptions filled, the revenue generated over a specified time, and medication error reports. 

Automation can reduce medication errors if it is implemented properly because it reduces the number of manual functions necessary to complete a task, thus reducing the chance for mistakes. Automation has helped to reduce the time that pharmacists spend preparing, labeling, and packaging medications, and this time can be reallocated to pharmaceutical care activities (Lewis, Albrant, and Hagel, 2002). 

Carey RG, Teeters JL. 1995. CQI case study Reducing medication errors. Joint Comm J Qual Improv 21 232. 

Although it might be difficult to prevent adverse medication events attributable to idiosyncratic causes, there are systems to account for both the acts of commission and the acts of omission in the medication use process. For an excellent review of current and proposed actions to reduce medication errors from acts of commission, the reader is referred to the efforts and publications of the Institute for Safe Medication Practices. This chapter focuses on acts of omission, or developing and implementing systems for the accountability of patient medication use outcomes. 

Source From NCC MERP council recommendations to reduce medication errors associated with verbal medication orders and prescriptions, adopted February 20, 2001. 

Gordon, B.M. Making the Formulary Safe General Strategies for Reducing Risks. ASHP Medication Use Safety Learning Community, Baltimore, June 2002. NCC MERP council recommendations to reduce medication errors associated with verbal medication orders and prescriptions, adopted February 20, 2001. Available at www.nccmerp.org/council2001-02-20.html, accessed January 9, 2004. 

The shortage of pharmacists could hinder the important role pharmacists play in reducing medication errors in all practice settings. 

Research methods on medication error data are not standardized. Therefore, they are subject to some limitations in generalizability. Because widespread interest in developing scientific approaches for reducing medication error is relatively recent, there are few well-established methods for conducting research in this held. However, funding for research in safe medication use and error reduction is available from several public and private sources, including the Agency for Healthcare Research and Quality. 

To identify opportunities for reducing medication errorS/ it is important that each error be carefully reviewed by a limited number of individuals to gain intimate knowledge of each reported incident. Collection and classification of error data must be followed by use of a careful epidemiological approach to problem solving at the system level. Narrative data which may not be seen by looking at the categorical data alone/ can be used to provide important details about proximal causes and latent error that may have contributed to the event. Success in this type of error reduction requires the reviewers to read between the lineS/ look for common threads between reports/ and link multiple errors that are the result of system weaknesses. 

The traditional system of providing patient care— wherein physicians initiate drug therapy, pharmacists dispense medications, and nurses administer medica-tion.s—is often run in a disjointed fashion. This results in potentially avoidable adverse drug events that contribute to poor patient outcomes and increased medical costs. Efforts aimed at modifying the current processes of care to enhance efficiency of workflow, improve patient outcomes, and reduce medication errors arc needed. 

The key to reducing medication errors lies in learning effectively from failures. Since its founding in October 1999, ISMP—Spain has maintained a national notification error reporting program. The principal objective of this program is to obtain information on medication errors and their causes in order to establish and transmit practical recommendations to prevent the recurrence of the errors. 

---