Medication Error Reduction Strategies

Medication Error Reduction Ideas From Maryland Directors of Pharmacy ISMP Medication Safety Self Assessment

I. Patient Information

#1. Essential patient information is obtained, readily available in useful form, and considered when prescribing, dispensing, and administering medications.

• Develop an automated system to prompt the pharmacist during order entry when the dosage of a really excreted drug is potentially incorrect.
• Develop protocols to allow pharmacists to automatically alter the dose of selected drugs based on renal function. 
• Utilize “Pyxis Profilingâ” to allow pharmacists to check drug dispensing prior to drug administration.
• Interface the pharmacy order entry system with the laboratory system so that appropriate laboratory values will be displayed during order entry of drugs with a narrow therapeutic index.

II. Drug Information

#2. Essential drug information is readily available in useful form and considered when ordering, dispensing, and administering medications.

• Assign decentralized pharmacists to Critical Care and Medical /Surgical areas primarily to help with monitoring medication use.  Satisfaction for this initiative among nurses and physicians is high.
• Deploy unit-based pharmacists on floors that use a large amount of high alert medications (e.g., chemotherapy).
• Implement automated dose range checking for narrow therapeutic medications and chemotherapy.
• Provide electronic drug information (e.g., Micromedexâ) availability from computer stations on each nursing unit.
   

#3.  A closed drug formulary system is established to limit choice to essential drugs, minimize the number of drugs with which practitioners must be familiar, and provide adequate time for designing safe processes for the use of new drugs added to the formulary.

III. Communication of Drug Orders and Other Drug Information

#4. Methods of communicating drug orders and other drug information are standardized and automated to minimize the risk for error.

• Institute a hospital-wide campaign using lectures, posters and newsletters to discuss safe order writing practices (e.g., inappropriate use of abbreviations, decimal points, etc.)
• Establish an aggressive “document legibility” policy.
• When an order is changed as a result of the pharmacist calling the prescriber, the pharmacist writes a verbal order in the pharmacy to discontinue the incorrect order and to initiate the new order.  The original copy of the verbal order is sent to the floor with the medication to be placed into the patient’s chart.
• Use Personal Digital Assistants (e.g., Palm Pilotsâ) for patient and drug information.
• Institute the use of protocol-based drug therapy managed by pharmacists.
• Present “Safe Order Writing Tips” to the Performance Improvement Committee and Medical Executive Committee (e.g. write out “units,” don’t use O.D. for right eye, don’t use leading decimals).  Also insert the tips in the physician’s newsletter.
• Develop a weight based heparin infusion protocol to decrease the potential for adverse reactions associated with heparin.
• Evaluate medication trends to identify clusters of medication errors or “near-misses.”  Develop and implement system changes to address these issues.
• Develop and implement an automated MAR to minimize manual transcription.
• Develop and use preprinted order forms for complex medication orders or high-alert drugs (insulin, opiates, etc.).
• Implement physician order entry systems.
• Develop a patient handout to teach patients about the safe use of medications.

IV. Drug Labeling, Packaging, and Nomenclature

#5. Strategies are undertaken to minimize the possibility of errors with drug products that have similar or confusing manufacturing labeling/packaging and/or drug names that look and sound alike.     

• Use auxiliary labels, i.e. “check dosage” when the dose dispensed is not unit of use, (e.g., 2 tablets or ½ tablet).
• Remove or separate look alike and sound alike drugs.
• Utilize special labeling for drugs that are easily confused, such as Oxycontin and Oxycodone.
• Republish alerts from the FDA, ISMP, and JCAHO (e.g. Avandia and Coumadin, Lamictal and Lamisil) in institutional newsletters.

#6.  Readable labels that clearly identify drugs are on all drug containers, and drugs remain labeled up to the point of actual drug administration.

Review the print fonts used on labels to assure that they are legible.

V. Drug standardization, storage, and distribution

#7. IV solutions, drug concentrations, doses, and administration times are standardized whenever possible.

• Use commercially obtained standardized-concentration IV solutions whenever possible.
• Use standardized concentrations of infusions, in particular heparin, insulin and narcotics.
• Place standardized IV drip charts in patient care areas.
• Place standardized dosing cards in emergency drug boxes.

#8. Medications are delivered to patient care units in a safe and secure manner and available for administrations within a time frame that meets essential patient needs.                   

#9. Unit-based floor stock is restricted.

• Minimize stock of medications stored on nursing that is available for use prior to the pharmacist’s review of an order.
• Provide 24-hour pharmacist services.
• For non-24 hour pharmacy services, do not allow non-emergency access into the pharmacy after hours.  Use an automated dispensing machine instead.

#10. Hazardous chemicals are safely sequestered from patients and not accessible in drug preparation areas.

Remove concentrated KCl, esmolol, and NaCl solutions from patient care areas.

VI.  Medication Delivery Device Acquisition, Use, and Monitoring

#11 The potential for human error is mitigated through careful procurement, maintenance, use, and standardization of medication delivery devices.

• Establish a policy to prohibit use of a parenteral syringe for the administration of a non-parenteral dose of medication.
• Make oral syringes available to all nursing units.
• Label both the proximal and distal ends of parenteral infusion tubing to clearly distinguish between lines such as epidural and intravenous lines.

VII. Environmental Factors

#12. Medications are prescribed, transcribed, prepared, dispensed, and administered in a physical environment that offers adequate space and lighting and allows practitioners to remain focused on medication use without distractions.

• Reduce traffic, noise and conversation in pharmacy areas where calculations, transcriptions and other critical duties are conducted to minimize distraction to pharmacists and technicians.

#13. The complement of qualified, well-rested practitioners matches the clinical workload without compromising patient safety.

VIII. Staff Competency and Education

#14. Practitioners receive sufficient orientation to medication use and undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices.

#15. Practitioners involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused.

• Target practitioner education through the P&T committee, medical staff committees, the physician lounge and through newsletters.
• Design and implement departmental Adverse Drug Event (ADE) posters as a means to communicate such items as ISMP newsletter information and ADE trending reports.
• Utilize lunchtime meetings with staff to communicate the results of ADE trending and actions taken to reduce ADEs or medication errors. 
• Publish a regular medication safety article in the pharmacy newsletter.

IX. Patient Education

#16. Patients are included as active partners in their care through education about their medications and ways to avert errors.

X. Quality Processes and Risk Management

#17. A non-punitive, system-based approach to error reduction is in place and supported by senior administration and the board of trustees/directors.

• Implement a non-punitive reporting system (see ISMP website for best example of non-punitive reporting, Frederick Memorial Hospital).
• Create an adverse drug event report that is user-friendly and customized for different practice sites to encourage reporting.
• Develop or redesign the medication error reporting process to obtain timely information that is easy to trend.
• Consider using the Medication Error system developed by the United States Pharmacopoeia (MedMarxâ). 

#18. Practitioners are stimulated to detect and report errors, and multidisciplinary teams regularly analyze errors that have occurred within the organization and in other organizations for the purpose of redesigning systems to best support safe practitioner performance.

• Form a team to regularly review and evaluate the hospital’s medication errors in detail.
• Complete the ISMP medication safety survey and form workgroups to address deficiencies.
• Establish a multidisciplinary Medication Error Team with representatives from all nursing units.
• Review the article “The Ten Most Common Lethal Medication Errors in Hospital Patients” with a multidiscipline group (Hospital Pharmacy Vol 35, May 2000, p 470).  Make changes based on recommendations from the meeting.
• Review policies and practices related to the medications listed in the JCAHO Sentinel Event Alert (see the JCAHO website).  Develop and implement changes as a result of the review.
• Develop a Medication Safety sub-committee of the Pharmacy and Therapeutics Committee.
• Report activities involved with medication error review to senior level committees such as the Hospital Board PI Council.
• Acquire an ISMP subscription to regularly review external errors.
• Send a “thank you letter” from the COO to employees reporting adverse drug reactions for the first time.  The letter comes with an angel pin, representing a “Guardian Angel”, to encourage guarding patient’s safety by reporting. 
• Use a standard form to document error communication among staff and the actions taken (if any) by the Medication Safety Committee.
• Use staff nurses and staff pharmacists as adverse drug event reviewers.

#19. Simple redundancies that support a system of independent double checks or an automated verification process are used for vulnerable parts of the medication system to detect and correct serious errors before they reach patients.

• Implement double check systems for all infusions of insulin, chemotherapy, and narcotics.

#20. Proven infection control practices are followed when storing, preparing, and administered medications