Wrong dose, missing doses, and wrong medication are the most commonly reported administration errors. Contributing factors to patient and caregiver error include low health literacy , poor provider—patient communication, absence of health literacy, and universal precautions in the outpatient clinic. Both low- and high-tech strategies have been designed to ensure safe medication administration and align with the nine rights of medication administration.
Many low-tech strategies support all nine rights, including the use of standardized communication strategies and independent double check workflows. Standardized communication : Health system communication standards are used to ensure right medication.
Additionally, standard abbreviations and numerical conventions are recommended by The Joint Commission. Of note, leading and trailing decimals i. Patient Education : To mitigate risk of error in the home, it is important for health care professionals to use clear communication strategies and routinely provide education to patients, especially when medication regimens are modified.
Patient education is a core component of medication management, particularly with high-risk medications such as anticoagulation therapy. Patients are educated routinely to ensure understanding of indication for therapy, intended outcomes, and signs and symptoms of adverse events. To help mitigate of wrong dose errors, warfarin tablet colors are standardized by their strength across all manufacturers. Patients are often advised to double check their tablet color upon getting a new prescription refill.
Optimizing Nursing Workflow to Minimize Error Potential : In health care settings, distractors during the medication administration process are common and associated with increased risk and severity of errors. Minimizing interruptions during medication administration and building in safety checks through standardized workflows are key strategies to facilitate safe administration. There are many challenges associated with a true distraction-free zone; a study assessing feasibility of a "do not interrupt" bundle found that it was moderately effective but had limited acceptability and sustainability.
Areas of increased high-risk medications administrations, such as the intensive care unit or emergency department, may have decreased compliance with non-interruption zones due to workflows and frequency of medication passes and titration events.
Health systems should identify the area where medication administration preparation by nurses occurs to ensure that minimal disruptions are present i. Additionally, strategies such as independent double checks are part of optimizing medication safety through nursing workflows. The Institute for Safe Medication Practices ISMP also recommends judicious use of independent double checks involving two different nurses to intercept errors prior to administration with key high-alert medications.
Research by Campbell et al. Due to the additional time burden added to existing nursing workload, these double checks should be strategically targeted to the highest-risk medications and processes. Some medications are available in a specific format to ensure the correct route is utilized during administration. For example, the epinephrine auto injector EpiPen for treatment of anaphylaxis is provided in a ready-to-use pen.
This device, used for intramuscular injection in an emergency, does not connect to an intravenous IV line, thus preventing unintended administration via the IV route.
Another crucial educational tool for health systems is the use of medication pass audits or medication safety rounds. Focusing in on High-Risk Agents : Some classes of medications have a higher likelihood to result in patient harm when involved in an administration error. The ISMP recommends a multipronged approach to mitigating risk with use of these agents. Strategies to mitigate potential for an administration error include protocolized prescribing, simplified instruction, robust documentation, and use of standardized administration practices such as dual nurse verification at the bedside.
Health systems are encouraged to develop robust guidelines for use of these agents. Standardized labeling, clear storage requirements, and various clinical decision support strategies are used to ensure correct medication selection and administration technique. The appearance of the medication itself may serve as a valuable safeguard. As an example, one type of eye drops prostaglandins has a turquoise cap on the bottle, across all manufacturers, while another completely different type of eye drop has a pink cap steroids.
This distinguishing feature may be helpful for caregivers and patients alike, especially given that low-vision patients frequently use these drops. Similar techniques are employed with institutional labeling. If a medication is supplied in a consistent manner with specific labeling, this may also reduce error. Pharmacy-prepared emergency kits frequently employ standardized labeling and instructions for this reason. High-tech solutions commonly implemented within health systems include: barcode scanning of medication to ensure right medication, patients arm bands to confirm the right medication and the right patient, and s mart infusion pumps for IV administration to confirm the right administration rate a derivative of right dose and route with technology that inhibits over- and underdosing of titratable drips during pump programming.
Barcode medication administration: When used appropriately, barcode medication administration BCMA technology reduces errors in health system settings by using barcode labeling of patients, medications, and medical records to electronically link the right dose of the right medication to the right patient at the right time. However, BCMA is subject to a number of usability issues and workarounds that can degrade its effectiveness in practice.
Users may encounter blockades in the BCMA workflow, for example, when the patient's arm band is not readable, the medication is not labeled or not in the system, or the scanning equipment malfunctions. A Dutch study using direct observation in four hospitals found that nurses used workarounds to solve BCMA workflow blockades in more than two-thirds of medication administrations, and workarounds were associated with a threefold higher risk of medication error.
Although smart pumps offer numerous safety advantages, they are also prone to implementation and human factors problems, such as difficult user interfaces and complex programming requirements that create opportunities for serious errors. Use of the drug library to ensure accurate pump programming is a key workflow step; not using the drug library as intended may negate the benefits of smart pump technology.
Given the complexity of manual pump programming, technologic advances allow for smart pump interoperability with the EHR, which allows the smart infusion pump screen to be pre-populated with information from the EHR. With an interconnected system of prepopulated smart pumps, additional resources may be needed to keep the system working its best. Challenges include keeping DERS in the smart pump aligned with most current hospital practice, ensuring standardization across care areas and devices, and data collection and ongoing quality improvement.
Some new technology supports the caregiver in assessing for the correct patient response to a medication. If retention of CO2 is detected, above a set threshold, this may indicate over sedation and respiratory depression. Based on this trigger, the pump can stop the PCA infusion, which may, in turn, reduce the possibility of further respiratory decline.
While this a helpful tool, manual assessment of patient response for medication therapy still remains of the upmost importance. Steps in the medication pathway are complex and interconnected.
For example, FDA reviews:. After drugs are approved for marketing in the United States, FDA monitors and evaluates medication error reports.
FDA may require a manufacturer to revise the labels, labeling, packaging, product design or proprietary name to prevent medication errors. Pharmacopeia, and researchers to understand the causes of medication errors, the effectiveness of interventions to prevent them, and to address broader safety issues that may contribute to medication errors.
Getting the right drug to the right patient FDA also put into place rules requiring barcodes on certain drug and biological product labels. Barcodes allow healthcare professionals to use barcode scanning equipment to verify that the right drug -- in the right dose and right route of administration -- is being given to the right patient at the right time.
This system is intended to help reduce the number of medication errors that occur in hospitals and other healthcare settings.
FDA has published several guidances to help manufacturers design their drug labels, labeling, packaging, and select drug names in a way to minimize or eliminate hazards that can contribute to medication errors. To avoid errors and encourage safe use of drugs, the guidance recommendations include:. Over-the-counter and prescription drug labeling According to a Harris Interactive Market Research Poll conducted for the National Council on Patient Information and Education and released in January , consumers tend to overlook important label information on over-the-counter OTC drugs.
Modeled after the Nutrition Facts label on foods, Drug Facts helps consumers compare and select OTC medicines, and follow instructions. The label clearly lists active ingredients, inactive ingredients, uses, warnings, dosage, directions, and other information, such as how to store the medicine.
In , FDA revised its rules for the content and format of prescribing information for prescription drug and biological products. The new look helps healthcare professionals find the information they need more easily and quickly. Consumers play an important role Consumers can also play an important role in reducing medication errors.
Here are some drug safety tips:. Serious harmful results of a medication error may include: Death Life threatening situation Hospitalization Disability Birth defect. This definition reminds us of the distinction between the drug itself the active component and the whole product, which also contains supposedly inactive excipients. Although the definition covers a wide range of compounds, it does not include medications when they are used to probe systems for non-diagnostic purposes, such as the use of phenylephrine to study baroreceptor reflexes in a physiological or pharmacological experiment.
All those who deal with medicines should establish or be familiar with such standards. They should institute or observe measures to ensure that failure to meet the standards does not occur or is unlikely. Everybody involved in the treatment process is responsible for their part of the process. Some medication errors result in ADRs but many do not; occasionally a medication error can result in an adverse event that is not an ADR for example, when a cannula penetrates a blood vessel and a haematoma results.
The overlap between adverse events, ADRs, and medication errors is illustrated in the Venn diagram in Figure 1. The precise frequencies of medication errors are not known. The method of detection can affect the estimated frequency. For example, in a UK hospital study of 36 medication orders, a prescribing error was identified in 1.
Wrong label information and instructions were the most common types of errors. However, it is important to detect medication errors, whether important or not, since doing so may reveal a failure in the treatment process that could on another occasion lead to harm.
There is also evidence that the death rate from medication errors is increasing. From to the numbers of deaths from medication errors and adverse reactions to medicines used in US hospitals increased from to 15 and from to the annual number of deaths from medication errors in the UK increased from about 20 to just under When errors are detected, they can cause much dissatisfaction.
The best way to understand how medication errors happen and how to avoid them is to consider their classification, which can be contextual, modal, or psychological. Contextual classification deals with the specific time, place, medicines and people involved. Modal classification examines the ways in which errors occur for example, by omission, repetition or substitution.
Psychological classification is to be preferred, as it explains events rather than merely describing them. Its disadvantage is that it concentrates on human rather than systems sources of errors. The following psychological classification is based on the work of Reason on errors in general. There are four broad types of medication errors labelled 1—4 in Figure 2. A classification of types of medication errors based on psychological principles.
Rule-based errors using a bad rule or misapplying a good rule —for example, injecting diclofenac into the lateral thigh rather than the buttock. Proper rules and education help to avoid these types of error, as do computerized prescribing systems. Action-based errors called slips —for example, picking up a bottle containing diazepam from the pharmacy shelf when intending to take one containing diltiazem.
In the Australian study mentioned above most errors were due to slips in attention that occurred during routine prescribing, dispensing or drug administration. A subset of action-based errors is the technical error—for example, putting the wrong amount of potassium chloride into an infusion bottle. This type of error can be prevented by the use of checklists, fail-safe systems and computerized reminders. Memory-based errors called lapses —for example, giving penicillin, knowing the patient to be allergic, but forgetting.
These are hard to avoid; they can be intercepted by computerized prescribing systems and by cross-checking. For some examples of prescription errors see Table 1.
Examples of other types of medication errors under the same headings are given in reference 8. For example, working overtime with inadequate resources, poor support, and low job security all contributed to an increased risk of medication errors by nurses.
Improved education and improved working conditions, including better induction processes, should reduce the risk of errors that are due to these factors; a national prescription form would help. One difficulty in detecting errors is that those who make them fear disciplinary procedures and do not want to report them. However, some systems for voluntarily reporting medical errors are of limited usefulness, because reports often lack details and there is incomplete reporting and underreporting.
Errors in prescribing can be divided into irrational prescribing, inappropriate prescribing, ineffective prescribing, underprescribing and overprescribing, and errors in writing the prescription. Failing to prescribe an anticoagulant for a patient in whom it is indicated underprescribing or prescribing one when it is not indicated overprescribing are different types of error from errors that are made when writing a prescription.
A rational approach can result in inappropriate prescribing, if it is based on missing or incorrect information. If, for example, one does not know that another prescriber has already prescribed paracetamol unsuccessfully for a headache, a prescription for paracetamol might be rational but inappropriate.
Consider an example from my own practice. Her doctor reasoned as follows:. Her doctor should have reasoned as follows:. This stresses the importance of understanding the relation between the pathophysiology of the problem and the mechanism of action of the drug see below. Ineffective prescribing is prescribing a drug that is not effective for the indication in general or for the specific patient; it is distinct from underprescribing see below. One would expect ineffective prescribing to be minimized by the use of guidelines, but there is conflicting evidence; prescribing guidelines may be ineffective unless accompanied by education or financial incentives.
Underprescribing is failure to prescribe a drug that is indicated and appropriate, or the use of too low a dose of an appropriate drug. The true extent of underprescribing is not known, but there is evidence of significant underprescribing of some effective treatments, such as angiotensin converting-enzyme inhibitors for patients with heart failure 36 and statins for hyperlipidaemia. The sources of underprescribing include fear of adverse effects or interactions, failure to recognize the appropriateness of therapy, and doubts or ignorance about likely efficacy.
Cost may play a part. In a study of the relation of underprescribing to polypharmacy in elderly patients, the probability of underprescribing increased significantly with the prescribed number of drugs. Overprescribing is prescribing a drug in too high a dosage too much, too often or for too long. In some cases treatment is not necessary at all. For example, among hospital patients who were given a proton pump inhibitor treatment was indicated in only half.
Overuse of antibiotics is well known and much discussed. A systematic review of 55 trials showed that no single strategy or combination of strategies was better than any other and none was highly effective, although the authors singled out active education of clinicians as a strategy to pursue.
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