Most of what has been learned in recent years about how to reduce medication errors and increase patient safety is based on two principles. First, individuals, by the very nature of being human, are vulnerable to error. Although individuals are the focus of the error, errors happen because of the systems in which those individuals work. As a result, reducing error will require us to design and implement more error-resistant systems. Second, we have to create an environment in which we can learn from failure - a safe, non-punitive environment that supports candid discussion of errors, their causes, and ways to prevent them.
These principles have a common denominator - they require the leadership and commitment of senior executives, medical, nursing, and clinical staff to create change within our organizations.
Common Sources of Error
Medication systems in hospitals are complex and multi-layered, involving many steps and many individuals. According to experts, this complexity increases the probability of failure. While many errors are caught before they can cause harm, it can be tragic whenever a patient's safety is compromised. Error can occur at any stage - prescribing, ordering, dispensing, administering, or monitoring the effects of a medication. According to the Institute for Safe Medication Practices, some common sources of medication error in health systems include:
Unavailable Patient Information: Critical patient information (diagnoses, lab values, allergies, drug contradictions, etc.) is often unavailable to pharmacy, nursing, and medical staff prior to dispensing or administering drugs.
Unavailable Drug Information: Pharmacists often are not readily available on patient care units and written resources may not be up-to-date, which can lead to dose miscalculations or ignorance of drug interactions. Because errors occur most often during the prescribing and administration stages, accessible drug information must be readily available and close at hand for all staff who prescribe and administer drugs.
Miscommunication of Drug Orders: Failed communication is at the heart of many errors. This includes poor handwriting, confusion of drugs with similar names, careless use of zeroes and decimal points, confusion of metric and apothecary systems, use of inappropriate abbreviations, ambiguous or incomplete orders, and, sometimes, conflicts between practitioners.
Problems with Labeling, Packaging and Drug Nomenclature: Most drugs are dispensed through unit dose systems that parse medications into smaller-sized doses. These systems, however, do not always provide for thorough preparation, packaging, and labeling of medications, with screening and checking by both nursing and pharmacy personnel, and they may not be available throughout every unit in the hospital (e.g., ERs and ICUs). Drug administration procedures often do not ensure that medications remain labeled until they reach the patient's bedside, a frequent source of error.
Drug Standardization, Storage, and Stocking: Stocking multiple concentrations of the same drug, or storing drugs in look-alike containers or in ways that obscure drug labels, may contribute to error. Lack of safety procedures for use of automated dispensing technology or inadequate check systems may also contribute to errors.
Drug Device Acquisition, Use and Monitoring: Lack of standardization in drug delivery devices, improper default settings, unsafe equipment (e.g., free-flow infusion pumps), and the lack of independent check systems for verifying dose and rate settings can all contribute to device-related errors.
Environmental Stress: Environmental factors like lighting, heat, noise, and excessive interruptions, can affect individual performance. The process of transcribing orders is particularly vulnerable to distractions in the environment, as staff transcribing orders are exposed to noise, interruptions, non-stop unit activity, and too-long or double shifts.
Limited Staff Education: Many practitioners are not as aware as they should be of situations within their own organizations that have been reported as error-prone, or of similar information published in professional literature.
Limited Patient Education: Medication use is a multi-step, multidisciplinary process that begins and ends with the patient. Patient education about medications - what they are taking, why they are taking it, and how they should take it - is essential to successful medication administration. Patients can be partners in the prevention of error while hospitalized and need to be educated to safely self-administer medications when they go home.
Quality Improvement Processes and Risk Management: Health facilities need systems for identifying, reporting, analyzing, and correcting errors and identifying trends, and measurement systems for tracking the effect of system changes. Also, organizations need to take into consideration information from outside sources about errors that have occurred elsewhere. But above all, health organizations need to cultivate a non-punitive approach to error that will encourage frank identification and analysis of errors when they occur.
Steps for Improving Medication Safety
These potential sources of error can be controlled if we design safer systems. With this in mind, the AHA has attached to this advisory a list of successful practices for improving medication safety and for improving overall patient safety within our hospitals and health systems. We encourage your team to review this list of recommendations, plan for implementation, and begin to track your progress.
The recommendations were culled from several reliable sources that are leaders in the effort to reduce and prevent medication errors, and we are grateful for their pioneering efforts. This list includes those organizations, as well as other resources for your organization's efforts.
- American Society of Health-System Pharmacists (www.ashp.org)
- American Society for Healthcare Risk Management (www.ashrm.org)
- Institute for Healthcare Improvement (www.ihi.org)
- Institute of Medicine (www.national-academies.org)
- Institute for Safe Medication Practices (www.ismp.org)
- Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org)
- Massachusetts Hospital Association (www.mhalink.org)
- Massachusetts Coalition for the Prevention of Medical Errors (www.macoalition.org)
- National Coordinating Council on Medication Error Reporting and Prevention (www.nccmerp.org)
- National Patient Safety Foundation (www.npsf.org)
- U.S. Pharmacopeia (www.usp.org)
- Cohen, Michael R., Ed. Medication Errors. Washington, D.C. American Pharmaceutical Association. 1999. (Contains a special chapter on high-alert medications and dangerous abbreviations; rich with insight and practical advice on reducing the risk of error.)
- Corrigan, Janet, et al. To Err is Human: Building a Safer Health System. Washington, D.C. National Academies Press. 1999. (Comprehensive overview of medical error, containing many practical suggestions and recommendations from several trusted sources.)
- Leape, Lucian, et al. Reducing Adverse Drug Events. Boston, MA: Institute for Healthcare Improvement. 1998. (Concepts to reduce adverse events and a model for improvement.)
Patient Information Brochures
- Your Role in Safe Medication Use: A Guide for Patients and Families is available from the Massachusetts Hospital Association at www.mhalink.org
- Partners in Quality: Taking an Active Role in Your Health Care is available from the Hospital & Healthsystem Association of Pennsylvania at www.haponline.org
- How to Take Your Medications Safely is available from the ISMP at www.ismp.org
- Just Ask! is available from the U.S. Pharmacopeia at www.usp.org
Information on Safe Medication Practices
From the Institute for Safe Medication Practices
- ISMP Medication Safety Alert!
- Urgent Error Advisories
From the U.S. Pharmacopeia
- Dangerous Abbreviations
- Practitioner Reporting Alerts
- Drug Quality Alerts
- Look-alike Sound-alike Name Lists
From the Joint Commission on Accreditation of Healthcare Organizations
- Sentinel Event Alerts
for Improving Medication Safety
Easily implemented changes (process redesign)
The following steps can be implemented immediately by hospitals and health systems. They focus on standardization and simplification of medication system processes.
- Maintain and systematically use unit-dose distribution systems (either manufacturer-prepared or repackaged by the pharmacy) for all non-emergency medications throughout the hospital. Unit dose systems should include, in addition to packaging, systems for labeling and order screening.
- Stress the need for dose adjustment in children, older persons, and patients with renal or hepatic impairment.
- For example, limit the types of general purpose infusion pumps to one or two.
- Use written guidelines, checklists, dose limits, pre-printed orders, double-checks, special packaging, special labeling, and education.
- Remove concentrated potassium chloride/phosphate from floor stock.
- Limit the number of possible concentrations for a drug, particularly high-alert drugs like morphine and heparin. Such standardization will allow the use of premixed solutions from manufacturers or centralized preparation of IV medications in the pharmacy.
- Review JCAHO Sentinel Events Alert #11, Nov. 19, 1999. Also, review Chapter 5 of Michael Cohen's 1999 book, "Medication Errors," published by the American Pharmaceutical Association.
- Make updated information on new drugs, infrequently used drugs, and non-formulary drugs easily accessible to clinicians prior to ordering, dispensing, and administering medications (e.g., have pharmacists do rounds with doctors and nurses; distribute newsletters and drug summary sheets; use computer aids; and provide access to formulary systems and other internal resources).
- Review error potential for all new products, including a literature review, before any drug or procedure is approved for use; reassess six months to one year later.
- Provide physicians, nurses, pharmacists, and all other clinicians involved in the medication administration process with orientation and periodic education on ordering, dispensing, administering, and monitoring medications.
- Distribute information about known drug errors from outside organizations like the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia (USP).
- Patients should be educated in the hospital, at discharge, and in ambulatory settings about their medications, what they are taking, why they are taking it, and how to use it safely.
- Encourage patients to ask questions about their medications.
- Encourage health care providers to work with pharmacists on patient education when patients receive certain classes of medications or are discharged on more than five medications.
- Have a pharmacist available on-call when pharmacy does not operate 24-hours a day.
- Make the pharmacist more visible in patient care areas - consider having pharmacy personnel make daily rounds on units, or enter orders directly into computer terminals on patient care units.
- Avoid certain dangerous abbreviations (see ISMP and USP for examples); identify a list of unacceptable abbreviations that will not be used in your institution.
- Include all elements of the order - dose, strength, units (metric), route, frequency, and rate.
- Use full names (preferably generic).
- Use computerized reminders for look-alike and sound-alike drug names.
- Use metric system only.
- Use preprinted order sheets whenever possible in non-computerized order systems.
- Times of administration (for example, antibiotics)
- Packaging and labeling
- Storage (for example, placing medications in the same place in each unit)
- Dosing scales (for example, insulin, potassium)
- Protocols for the use and storage of high-alert drugs
Longer-term changes (systems redesign)
- Review policies for how your organization encourages reporting and analyzing errors throughout the institution.
- Encourage candid communication and feedback.
- Ensure no reprisals for reporting of errors. Reports will increase if you make it safe to report.
- Encourage the use of computer-generated or electronic medication administration records.
- Plan for the implementation of computerized prescriber order entry systems.
- Consider the use of machine-readable code (i.e., bar coding) in the medication administration process.
- Use computerized drug profiling in the pharmacy.
- Be a demanding customer of pharmacy system software; encourage vendors to incorporate and assist in implementing an adequate standardized set of checks into computerized hospital pharmacy systems (e.g., screening for duplicate drug therapies, patient allergies, potential drug interactions, drug/lab interactions, dose ranges, etc.).
... alternatively, use night formularies and careful drug selection and storage procedures. To facilitate medication distribution after hours, develop policies and procedures to ensure access to consultation with a pharmacist if a pharmacist is not available on-site.