Summary

The National Patient Safety Partnership, which includes the AHA, other health care organizations, and government agencies, last month urged providers to adopt practices that will reduce medication errors in clinical settings. The partnership's recommendations can help thwart errors associated with prescribing, purchasing, dispensing and administering medications. The coalition estimates as many as eight percent of hospitalized patients will have an adverse drug effect and that about 100,000 injuries or deaths each year can be attributed to drug interactions or dosage errors. The recommendations follow.

To reduce the occurrence of adverse drug events (events that can cause, or lead to, inappropriate medication use and patient harm)

Patients should:

  • Tell physicians about all medications (both prescribed and over-the-counter) they are taking, why they are taking the medications, and responses/reactions to them
  • Ask for information in terms they understand before accepting any prescribed medications

Providing organizations and practitioners can:

  • Educate patients
  • Note allergies and medications on patient records
  • Stress the need for dose adjustment in children and older persons
  • Use protocols to ensure proper use of high-hazard drugs (e.g. concentrated potassium chloride, chemotherapeutic agents, anticoagulants)
  • Computerize drug order entry
  • Use pharmacy-based I.V. and drug mixing programs
  • Avoid abbreviations. If abbreviations are used by a facility, they should be standardized throughout the facility
  • Standardize drug packaging, labeling, storage
  • Use "unit dose" drug systems (packaged and labeled in standard patient doses)

Purchasers can:

  • Require machine-readable labeling (barcoding)
  • Buy drugs with prominent display of name, strength, warnings
  • Buy "unit of use" packaging (also known as "unit dose")
  • Buy I.V. solutions with two-sided labeling
 

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