Medication errors are preventable. Your best defense is asking questions and being informed about the medications you take. Medication errors refer to mistakes in prescribing, dispensing and giving medications.
They injure hundreds of thousands of people every year in the United States. Yet most medication errors can be prevented. How can you protect yourself and your family? One of the best ways to reduce your risk of a medication error is to take an active role in your own health care. Learn about the medications you take — including possible side effects. Never hesitate to ask questions or share concerns with your doctor, pharmacist and other health care providers. Medication errors are preventable events due to the inappropriate use of medications.
Medication errors that cause harm are called preventable adverse drug events. If a medication error occurred, but didn't hurt anyone, it's called a potential adverse drug event. An example of a medication error is taking an over-the-counter product that contains acetaminophen Tylenol, others when you're already taking a prescription pain medicine that contains this exact ingredient. This mistake could cause you to take more than the recommended dose of acetaminophen, putting yourself at risk of liver damage.
Another example of a possible medication error is taking a depression medication called fluoxetine Prozac, Sarafem with a migraine drug called sumatriptan Imitrex. Both medicines affect levels of a brain chemical called serotonin. Taking them together may lead to a potentially life-threatening condition called serotonin syndrome. Symptoms of the dangerous drug interaction include confusion, agitation, rapid heartbeat and increased body temperature, among others.
Medication errors can happen to anyone in any place, including your own home and at the doctor's office, hospital, pharmacy and senior living facility. Kids are especially at high risk for medication errors because they typically need different drug doses than adults. Knowing what you're up against can help you play it safe.
The most common causes of medication errors are:. Knowledge is your best defense. If you don't understand something your doctor says, ask for an explanation. Whenever you start a new medication, make sure you know the answers to these questions:. Your doctor can help prevent medication errors by using a computer to enter and print or digitally send any prescription details, instead of hand writing one.
Asking questions is essential, but it isn't enough. Your health care providers can follow a process called medication reconciliation to significantly decrease your risk of medication errors.
Medication reconciliation is a safety strategy that involves comparing the list of medications your health care provider currently has with the list of medications you are currently taking. This process is done to avoid medication errors such as:. Medication reconciliation should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Transitions in care include changes in setting such as being admitted or discharged from the hospital , health care provider or level of care. 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. The healthcare industry utilizes a number of low-tech and high-tech strategies to mitigate risk of medication administration errors.
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Improvement Resources. About PSNet. The Fundamentals Primers Topics Glossary. All Content. Current Weekly Issue. Keep medication out of the reach of children 7. Learn about potential drug interactions and warnings. The responsibility for the prevention of medical errors rests not only with health care professionals and health care systems but also with the patients themselves. By being informed not only about the names of their medications but the reasons for their use, the times they should be administered and the correct dose, patients can act as the final check in the system.
The practice of carrying a continually updated list of medications can be invaluable in the event of an emergency or if patients cannot speak for themselves. This reduces the chance of miscommunications or misinformation. When patients take an active and informed role in his or her health care, many errors can be prevented. Prior Authorization Prior authorization programs are used by managed health care systems as a tool to assist in providing quality, cost-effective prescription drug benefits.
Improving patient safety by promoting appropriate drug use is an integral function of prior authorization programs. Medication errors can be reduced by prior authorization systems in various ways. First, a health plan may limit coverage to FDA-approved uses as well as unapproved uses that are substantiated by appropriate and adequate medical evidence.
Prior authorization may be used to protect against adverse events in highly contraindicated populations. A prior authorization program may also be employed to ensure that patients do not receive certain drugs, such as antibiotics, for exceedingly long durations that could put patients at increased risk for adverse events.
Overall, a well designed prior authorization program is a useful tool in promoting patient safety and reducing medication errors. Bar Coding One way in which electronic technology can improve patient safety and reduce medication errors is through the use of standard machine-readable codes "bar codes". Medication bar coding is a tool that can help ensure that the right medication and the right dose are administered to the right patient.
Pharmacists use the record as a tool to reduce medication errors by guarding against drug interactions, duplicate therapy and drug contraindications. The EPR can also help reduce medication errors by helping pharmacists monitor and audit utilization and by facilitating communication between health care providers to improve patient care.
E-prescribing Utilization of electronic prescribing by entering orders on a computer, better known as Computerized Physician Order Entry CPOE , is a technology that could help prevent many medication errors.
CPOE systems allow physicians to enter prescription orders into a computer or other device directly, thus eliminating or significantly reducing the need for handwritten orders.
E-prescribing and CPOE can reduce medication errors by eliminating illegible and poorly handwritten prescriptions, ensuring proper terminology and abbreviations, and preventing ambiguous orders and omitted information. Electronic DUR Due to the technology of the electronic prescription record, pharmacists are able to conduct prospective online drug utilization reviews DUR.
The online DUR process allows the pharmacist to conduct a review of the prescription order at the time it is presented for filling and proactively resolve potential drug-patient problems such as drug-drug interactions, over-use, under-use and medication allergies. Automated Medication Dispensing Automated medication dispensing systems are now widely used as a less labor-intensive method of dispensing medications. When utilized appropriately, automated medication dispensing systems help to reduce medication errors and improve patient safety.
Internal Quality Control Procedures Most medication dispensing settings have developed quality evaluation procedures. These practices provide workflow evaluation and error reporting analyses, which lead to excellent protection from medication error. These procedures and evaluations have led to several changes in standard practice for ambulatory pharmacy, generally adopted as acceptable professional practice. These changes have provided additional safety checks, such as image displays, as part of the final dispensing review process, and the addition of descriptive text on prescription labels.
These practices not only allow for final dispensing checks, but also allow for patient monitoring of consistency between label description and vial contents. Proactive system interventions also provide additional error prevention protection. Many pharmacies and commercial dispensing systems now provide messaging during the drug selection process.
When a drug is known to be subject to look-alike, sound-alike drug name confusion, the dispenser is alerted to double check that the appropriate agent has been chosen. In many dispensing environments DUR responses and resolutions are reviewed by an overview process.
When excessive overrides by a dispensing practitioner are detected, the overview process ensures that proper professional evaluation is being conducted to prevent errors such as those described in the previous DUR section.
It is very important that reporting and all subsequent activities are properly evaluated by a continuous quality improvement CQI process. A constantly evolving work flow improvement procedure provides maximum safety and is not designed solely for punitive reasons. Increasing pressures from litigation and liability issues should be sufficient for any ambulatory pharmacy entity to establish practices that demonstrate there are diligent efforts underway to protect patients from harmful medication errors.
In summary, medication errors are an unfortunate part of the health care delivery system. Health care provider attitudes must change in the approach to prevention of these errors. Patient education is an important aspect of any program to prevent medication misadventures.
Organizations such as ISMP, and the FDA, as well as individual managed care organizations can help to evaluate the cause of medication errors. The collection of error data and analysis in the health care delivery process will minimize the risk of medication errors and improve patient safety. The health care community must recognize that both people and systems contribute to medication errors. The focus should be on identifying the error-prone aspects of the medication use continuum with the goal of improving system safety and reliability through remedial action.
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