1. Medication Error Prevention
M. Lisa Pagnucco, BS Pharm, PharmD, BCACP Assistant Professor, Pharmacy Practice University of New England, College of Pharmacy
September 8th, 2013

2. Disclosure
I have no conflicts of interest to disclose.

3. Objectives
Discuss why a culture of safety is an important element to improve the medication use process in any practice setting.
Describe one example of an error occurring at each stage in the medication use process.
Explain one or more strategies used to reduce or eliminate errors identified at each stage in the medication use process.

4. The Problem: Scope and Cost
Preventable Medication Errors:
Occur in 3.8 million (inpatient admissions)
Occur in 3.3 million (outpatient visits)
$21 billion ($21,000,000,000)
$16.4 billion (inpatient)
$4.2 billion (outpatient)
Founded in 2002, NEHI is a nonprofit, independent health policy institute dedicated to transforming health care for the benefit of patients and their families.
NEHI brings together diverse perspectives from the health care community across the country – including patients, payers, providers, universities, hospitals and not-for-profit institutions, and for-profit companies and associations – to find mutual solutions to mutual health care problems through collaboration, research and transformation.
NEHI is a nonprofit, health policy institute focused on enabling innovation that will improve health care quality and lower health care costs. Working in partnership with members from across the health care system, NEHI brings an objective, collaborative and fresh voice to health policy. We combine the collective vision of our diverse membership and our independent, evidence-based research to move ideas into action.
TO IMPROVE HEALTH CARE,
WE:
Harness the collective commitment of our membership.
Conduct independent research projects.
Inform and educate policymakers and health care leaders nationally.
Drive change by influencing health care policy and practice.
NEHI. (2011) Preventing Medication Errors: A $21 Billion Opportunity. Retrieved from Last accessed July 2012.

5. Estimates that 30 - 50% of $2.7 trillion annual US healthcare spending is……
wasteful.

6. What is a Medication Error?
What is an Error?
…The failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning).
An error may be an act of commission or an act of omission.
Institute of Medicine, 2004
What is a Medication Error?
…. “any error occurring in the medication use process.”
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10(4): 100–205.

7. Medication Use Process
The medication system, beginning with product selection through administration of the medication to the patient and monitoring the effects, involves significant complex processes.
  These processes are highly prone to failure which can result in operational inefficiencies or worse, medication errors with potential adverse outcomes to the patient. 
Understanding medication system design and contributors to system failure is the first step. 
The medication-use process is influenced by inter-connecting systems that define the way;
Information is managed,
The environment is structured, and
Human resources are handled
Cohen MR, Causes of Medication Errors. In: Cohen MR, ed. Medication Errors. Washington, DC: American Pharmacists Association;2007:57
Joint Commission International

8. Error of Commission Error of Omission
An act of doing something wrong that leads to an undesirable outcome or significant potential for such an outcome.
Example:
Ordering a medication for a patient with a documented allergy to that medication.
An act of failing to do the right thing that leads to an undesirable outcome or significant potential for such an outcome.
Example:
Failing to prescribe VTE prophylaxis for a patient after hip replacement surgery
Error: An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome. For instance, ordering a medication for a patient with a documented allergy to that medication would be an act of commission. Failing to prescribe a proven medication with major benefits for an eligible patient (e.g., low-dose unfractionated heparin as venous thromboembolism prophylaxis for a patient after hip replacement surgery) would represent an error of omission.  Errors of omission are more difficult to recognize than errors of commission but likely represent a larger problem. In other words, there are likely many more instances in which the provision of additional diagnostic, therapeutic, or preventive modalities would have improved care than there are instances in which the care provided quite literally should not have been provided. In many ways, this point echoes the generally agreed-upon view in the health care quality literature that underuse far exceeds overuse, even though the latter historically received greater attention. (See definition for Underuse, Overuse, Misuse.) In addition to commission vs. omission, three other dichotomies commonly appear in the literature on errors: active failures vs. latent conditions, errors at the sharp end vs. errors at the blunt end, and slips vs. mistakes.
AHRQ, Patient Safety Network (PSNet), Glossary

9. Patient Safety – Adverse Events
Beneficiaries.Source: OIG analysis of hospital stays for 780 Medicare beneficiaries discharged in October 2008.
DHHS. Office of Inspector General. (2010) Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Retrieved from Last accessed July 2012.

10. Established by National Academy of Sciences in 1970 to examine policy issues related to the health of the public
The Quality of Health Care in America project (1998)
To develop a strategy for quality improvement in next ten years
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the
examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The first report from the project was released in 1999: “To Err is Human: Building a Safer Health System”

11. “To Err is Human: Building a Safer Health System”
Estimated annually in U.S.:
44,000 to 98,000 patient deaths from patient care errors
More than 1 million patients injured
7,000 deaths from medication errors
Landmark report, 1999
Examined impact of medical errors
Identified errors are caused by faulty system
Processes and conditions that lead people to make mistakes or fail to prevent them
Suggested national strategy for improvement
The first report from the 1998 project formation, Quality of Health Care in America.
Referred to as a landmark report for jumpstarting the Patient Safety and eventually the quality movement
The report addressed the significant impact of medical errors and began a frank discussion about the system issues setting humans up for failure.
Shocking to many, the report estimated almost 100,000 deaths ANNUALLY in the US as a result of health care and greater than 1 million patient injuries.
Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.

12. “To Err is Human: …1999” Strategies for Improvement
Establish a national focus to create leadership, research, tools and protocols to enhance the knowledge base about safety.
Identify and learn from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems.
Raise performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and group purchasers of health care.
Implement safety systems in health care organizations to ensure safe practices at the delivery level.
Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.

13. “Crossing the Quality Chasm: A New Health System for the 21st Century”
Report released in 2001
Health care harms patients frequently
Chasm:
The divide between the current health care and what health care could be like
Study how the health system can be reinvented to foster innovation and improve the delivery of care
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.

14. “Crossing the Quality Chasm:…2001” Strategies for Improvement
Six Aims for Improvement:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Six Aims for Improvement:
Built around core need for health care to be:
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.

15. “Preventing Medication Errors”
Report released in 2006
Adverse drug event (ADE):
Patient harm due to administration of a drug; may be preventable (related to any error in the medication use process) or non-preventable. 
Hospitalized patients:
One medication error per patient per day
Estimated annually in U.S.:
At least 1.5 million preventable ADEs
$3.5 billion additional costs annually
CMS requested IOM study the prevalence of such medication errors and formulate a national agenda to reducing these errors
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.

16. “Preventing Medication Errors” 2006 Strategies for Improvement
Improving the Patient-Provider Partnership
Allow and encourage patients to take a more active role in their care
Better communication with patients at all steps by all providers
New and Improved Drug Information Resources
Improve consumer access to information about medications
Electronic Prescribing and other IT Solutions
POC references, e-prescribing, EHR, HRO focus on medication safety
Drug Naming, Labeling and Packaging
Industry and agency collaboration to improve drug nomenclature, labeling and information sheets
CMS requested IOM study the prevalence of such medication errors and formulate a national agenda to reducing these errors
Importance of Patient Empowerment – what patients should expect from their providers (to be listened to and respected) and how they can help with safety (carry current list of meds, Rx, OTC, herbals, etc.) as well as allergy and contact information.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.

17. Preventing Medication Errors
Recommendation 1:
To improve the quality and safety of the medication- use process, specific measures should be instituted to strengthen patients’ capacities for sound medication self-management.
Patients’ right for safety and quality in health care
Patients should maintain an active list of all medications to which all providers have access.
Providers should educate patients about their medications.
Consultation on medications should be available to patients at key points in medication-use process.
e.g. admission, discharge, at pharmacy (transitions)
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

18. Box S-3 Patient Rights Patients have the right to:
Be the source of control for all medication management decision that affect them (that is, the right to self-determination).
Accept or reject medication therapy on the basis of their personal values.
Be adequately informed about their medication therapy and alternative treatments.
Ask questions to better understand their medication regimen.
Receive consultation about their medication regimen in all health settings and at all points along the medication-use process.
Designate a surrogate to assist them with all aspects of their medication management.
Expect providers to tell them when a clinical significant error has occurred, what the effects of the event on their health (short- and long-term) will be, and what care they will receive to restore their health.
Ask their provider to report an adverse event and give them information about how they can report the event themselves.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.

19. Issues for Discussion with Patients by Providers
Box S-5
Issues for Discussion with Patients by Providers
(Physicians, Nurses, and Pharmacists)
Review the patient’s medication list routinely and during care transitions.
Review different treatment options.
Review the name and purpose of the selected medication.
Discuss when and how to take the medication.
Discuss important and likely side effects and what to do about them.
Discuss drug-drug, drug-food, and drug-disease interactions.
Review the patient’s or surrogate’s role in achieving appropriate medication use.
Review the role of medications in the overall context of the patient’s health.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.

20. Preventing Medication Errors
Recommendation 2:
Government agencies (AHRQ, CMS, FDA, NLM) should enhance the resource base for consumer-oriented drug information and medication self-management support.
Pharmacy leaflets should be standardized.
NLM should be chief internet resource for consumers.
FDA, CMS, NLM should evaluate approaches for building a national network of drug information helplines.
FDA, CMS, NLM should confirm minimum dataset for public health records (PHRs).
National plan for widespread distribution of medication safety information should be developed.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

21. Preventing Medication Errors
Recommendation 3:
All health care organizations should make available to providers patient information and decision support tools.
Access to automated Point-of-Care reference information
Electronic prescribing
Effective use of well-designed technologies
Communication of patient-specific medication-related information
Monitoring for errors
Adopting a safety culture
Access comprehensive reference information
Communicate patient-specific medication information interoperably
Assess safety through active monitoring
By 2008, prescribers should have plans in place to e-prescribe and by 2010 write all and have pharmacies receive all electronically
Subject prescriptions to decision support
Have the appropriate competencies for the medication use process
Make effective use of technologies, which will vary by setting
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

22. Preventing Medication Errors
Recommendation 4:
Better labeling is needed, as are better methods for communicating medication information to consumers.
Risk/Benefit information for prescription drugs
Communication of drug information
FDA should develop guidance documents to industry for labeling and packaging.
Studies about design of labeling and information sheets should be done.
FDA should work with industry to develop a strategy for expanding unit-of-use packaging.
AHRQ should fund studies evaluating impact of samples on safety, prescribing behavior, and consumer choice.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

23. Drug Naming, Labeling, and Packaging Problems
Box S-6
Drug Naming, Labeling, and Packaging Problems
Brand names and generic names that look or sound alike
Different formulations of the same brand and generic drug
Multiple abbreviations to represent the same concept
Confusing word derivatives, abbreviations, and symbols
Unclear dose concentration/strength designations
Cluttered labeling – small fonts, poor typefaces, no background contrast, overemphasis on company logos
Inadequate prominence of warnings and reminders
Lack of standardized terminology
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.

24. Preventing Medication Errors
Recommendation 5:
Industry and government should collaborate to establish standards affecting drug-related healthcare information technology (HIT).
NLM take lead developing common drug nomenclature
AHRQ take lead organizing mechanisms for safety alerts
AHRQ take lead developing intelligent prompting mechanisms specific to a patient’s unique characteristics and needs; provider prescribing, ordering, and error patterns; and evidence-based best-practice guidelines
AHRQ take lead developing user interface designs based on principles of cognitive and human factors and clinical environment
AHRQ should support additional research for alert mechanisms, etc.
NLM and drug nomenclature
AHRQ and safety alert mechanisms by severity, frequency, and clinical importance, including:
Intelligent prompting
Human factors
Specifications for alerts.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

25. Preventing Medication Errors
Recommendation 6:
Congress should fund AHRQ to work with other agencies to develop a broad research agenda on safe and appropriate medication use, especially testing of error prevention strategies.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9*.

26. Preventing Medication Errors
Recommendation 7:
Oversight and regulatory organizations and payers should use (tactics) to motivate the adoption of practices that can reduce medication errors and ensure that providers have needed competencies.
Tactics (legislation, regulation, accreditation, and payment mechanisms and the media )
Payers and purchasers should provide explicit financial incentives.
CMS should evaluate a variety of strategies for medication therapy management.
Regulators should set minimum functionality standards for error prevention technologies.
States should enable e-prescribing.
State boards of pharmacy should undertake quality improvement initiatives related to community pharmacy practice.
Medication error reporting should be promoted by all.
Accreditors of professional education should require more training in improving medication management practices and clinical pharmacology.
Institute of Medicine. Preventing medication errors: quality chasm series. Washington, DC: National Academy Press, 2006.
Bates DW. Preventing medication errors: A summary. Am J Health-Syst Pharm 2007; 64;S3-S9.

27. Where Do Medication Errors Occur (%)
Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.

28. Where are errors caught?
Stage of Medication Use
Errors (%)
Interception (%)
Prescribing
39%
48%
Transcription
12%
33%
Dispensing
11%
34%
Administration
38% 2%
Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.

29. “We cannot change the human condition, but we can change the conditions under which humans work.”
Reason J. Human Error: models and management.
BMJ 2000;320:

30. The Swiss Cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory.
The Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory
Slices: barrier, safeguards, defences
Holes: active or latent failure conditions
Reason J. Human Error: models and management.
BMJ 2000;320:
©2000 by British Medical Journal Publishing Group

31. Swiss Cheese Model Active failures Latent failures
Unsafe acts by persons in direct contact with patient or system
Slips, lapses, fumbles, mistakes, procedural violations
‘Sharp end’ of process
RN, PharmD, MD, DO, RT
Administrative level decisions
Error provoking conditions
Long lasting weaknesses
‘Blunt end’ of process
Dormant; proactive vs. reactive
Slips: unconscious glitches often caused by faulty attention; “interchanged action schemas”␣
Lapses: memory failures␣
Mistakes: poor judgment, incorrect inference, faulty reasoning: “actions that go as planned, but the plan is inadequate to achieve its intended outcome”
AHRQ - A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.
The field of cognitive psychology classifies most tasks as involving either schematic behavior, tasks performed reflexively or "on autopilot," or attentional behavior, which requires active planning and problem-solving. The types of error associated with each behavior are also different: failures of schematic behavior are called slips and occur due to lapses in concentration, distractions, or fatigue, whereas failures of attentional behavior are termed mistakes and often are caused by lack of experience or insufficient training. In health care, as in other industries, most errors are caused by slips rather than mistakes, and checklists represent a simple, elegant method to reduce the risk of slips. Flight preparation in aviation is a well-known example, as pilots and air-traffic controllers follow pre-takeoff checklists regardless of how many times they have carried out the tasks involved. By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed for every patient, checklists have the potential to greatly reduce errors due to slips.

32. Safety Culture Project
A safety culture enables trust and quality improvement.
A safety culture empowers staff to speak up about:
Risks to patients
Report errors and near misses
Summary of knowledge, attitudes, behaviors and beliefs that staff share about importance of patient safety
AHRQ survey 2010:
1,032 hospitals, 472,397 hospital staff
56% felt mistakes would be held against them
54% had not reported any events in the previous 12 months

33. Traditional Approach to Errors
Fault of the individual
Physician, nurse, pharmacist
Trained for error-free practice
Reinforced by “blame game”
Trained to do work without thinking
Automatic

34. The Person Approach to Errors
Focused on unsafe acts by an individual
Unsafe acts are result of aberrant mental processes
Correction by reducing unwanted variability in human behavior
‘Bad things happen to bad people’
Focused on unsafe acts by an individual
errors, procedural violations
Unsafe acts are result of aberrant mental processes
forgetfulness, inattention, poor motivation, carelessness, negligence, recklessness
Correction by reducing unwanted variability in human behavior
fear, added procedures, disciplinary action, retraining, naming, blaming, shaming, threat of litigation
Approach - ‘bad things happen to bad people’

35. High Reliability Organizations (HROs)
The Systems Approach
High Reliability Organizations (HROs)
Organizations operating in hazardous conditions that have fewer than their fair share of adverse events
Preoccupation with possibility of failure
Study Safety rather than just Failures
Rehearse scenarios of failure
Workforce trained to expect errors, recognize and recover from them
Captain Chesley Sullenberger landed the US Airways flight 1549 on the Hudson River in January 2009

36. The Systems Approach - HROs
HROs: Aviation, Nuclear Power, Space Travel
Equally hazardous
As complex as healthcare
Design a system for safety:
Assume things will fail
Anticipate what should be done
Non-punitive reporting system
Encouraged to report
Space Shuttle Challenger, 1986; broke apart 73 seconds into its flight
AHRQ website in discussion about system safety

37. Organizational Safety Cultures
Fear of legal or criminal actions after an error
Associated with hiding or not reporting errors
Reduced likelihood of sharing ‘close calls’; missed opportunities to learn and prepare
‘Just culture’:
Address system issues that lead individuals to engage in unsafe behaviors
Maintains individual accountability by establishing zero tolerance for reckless behavior
Based on type of behavior associated with error, not the severity of error
e.g. refusal to perform a ‘time-out’ prior to su

39. Errors are……..Opportunities
Root Cause Analysis (RCA)
AFTER an error has occurred – ‘Reactive’
What DID happen, why, why, why?
Use results for system/process improvements
Failure Mode and Effects Analysis (FMEA)
BEFORE errors occur; anticipation – ‘Proactive’
What COULD happen, how and why?
Build safeguards into process before change

40. Patient Safety Organizations
Patient Safety and Quality Improvement Act of 2005
Authorized creation of Patient Safety Organizations (PSOs) to improve the quality and safety of U.S. health care delivery.
Encourages clinicians and health care organizations to voluntarily report and share quality and patient safety information without fear of legal discovery.
The Agency for Healthcare Research and Quality (AHRQ) administers the Patient Safety Act and Rule for PSO operations.

41. Institute for Safe Medication Practices (ISMP)
Non-profit, 501c (3) organization
Devoted to medication error prevention and safe medication use
ISMP is a certified PSO
Expert analysis of errors
Dissemination of medication error and safe medication use information for over 35 years; column in Hospital Pharmacy
Newsletters, seminars, consultant services
Michael Cohen, President, ISMP founder, Medication Safety Expert, Pharmacist

42. Suspicion: Mindfulness: Index of suspicion:
Awareness or concern for potentially serious underlying and unseen injuries or illness
Suspicion:
“the act or an instance of suspecting something wrong without proof or on very slight evidence, or a state of mental uneasiness and uncertainty.”
Mindfulness:
Defining characteristic of High Reliability Organizations (HROs)
Sense of unease and preoccupation with failure that arises from admitting the possibility of error, even with well-designed stable processes.

43. Where Do Medication Errors Occur (%)
Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.

44. Prescribing Challenges Improvements Missing information
References, patient, history, labs, home meds
Medications unfamiliar
Distractions
Cases, missing charts
Office hours and call
Pagers
Ordering process
NCR, verbal orders, telephone, hand written
Improved information access
Remote computer system access
Clinical decision support systems (CDSS)
Electronic drug, disease information
Electronic Health Record (EHR)
Use of checklists, care plans
Improved communication
Reduced phone time; less pager use, increased messaging and in person
Legibility, abbreviations strategies
Computerized Provider Order Entry (CPOE) or E-prescribing

45. Transcription Improvements Challenges Order appearance
Legibility, abbreviations, decimals, spaces
Order clarifications
Verification of calculations
Incomplete orders, paging
Pertinent labs, allergies, patient history
Appropriateness
Order transmission
Verbal, faxed, NCR
Safety – written and printed
“Do Not Use Abbreviations”
Pre-printed order forms/sets
QI/credentialing for legibility
Improved information access
Computer system interfaces
CDSS and informatics
Allergies, height/weight, pregnancy/lactation status
Scanning or CPOE
Minimize use of verbal orders
E-prescribing

46. ISMP Error Prone Abbreviations

47. ISMP Error Prone Dose Designations

48. Dispensing Improvements Challenges Environment Drug labels, drug names
Distractions, workload, stress, workflow, storage, poor light
Drug labels, drug names
Look-alike, sound-alike
Poor labels from Rx computer
High-risk medications
Rx system issues
Problematic drug database
Updates not timely
Medication shortages
Process/system evaluations
Ergonomics, lighting, staffing, reduce distractions, redesign storage, work flow
ISMP – identify LASA, high-risk
Guidance for computer labels
Resources - system maintenance
Staffing improvements
Scheduling based on workload
Technician support duties
Technology
Robotics, carousel, compounder, bar-code verification, biometrics

49. Administration Challenges Improvements Information: patient, drug
Age, height, weight, allergies, diagnoses, home medications
Reference books outdated
Dose admixtures and rates
IV admixture, calculate IV rate
Dose preparation from bulk
Order verification
Right order, med, patient
Maintain manual MAR
Distractions
Phones, pagers, call buttons
Missing or misplaced doses
Better Information Access
Computer system interfaces
Point-of-Care current drug info.
CDSS pertinent lab verification
Patient identification processes
USP 797 and TJC
SMART pumps
Electronic MAR
Bar Code Medication Administration
Automated Dispensing Cabinets
Reduced interruptions/distractions
Patient engagement

50. Partnering with the Patient to Prevent Medication Errors
Invite information sharing
Use clear communication
Assess and assist with medication adherence
Identify financial barriers
Health literacy awareness
Culturally competent care
Identify interpreter needs, hearing, or visual aids
Engage care managers
Support health/wellness
Facilitate safe transition

51. IOM Report 2006 Preventing Medication Errors
Patient Education to Avoid Medication Errors

54. National Patient Safety Foundation

55. Key Elements to Prevent Medication Errors
Create a culture of safety:
Empower staff, patients, caregivers to speak up
Report errors, near misses – process improvement
Share information about problems and solutions
Raise awareness of errors
Improve communication:
Between all providers, providers and patients/caregivers
Consider all communication forms for clarity and safety
Incorporate technology:
Consider highest risk error stages early
Engage expertise of end users before implementation
Revisit process change often for continual improvement

57. Question 1
All of the following examples are strategies to reduce errors at the administration stage of the medication use process except:
Bar code verification
Patient identification
Electronic prescribing
Patient education

58. Answer: Question 1
All of the following examples are strategies to reduce errors at the administration stage of the medication use process except:
Bar code verification
Patient identification
Electronic prescribing
Patient education

59. Question 2
In which of the following situations would conducting a Root Cause Analysis (RCA) be most appropriate?
A report for a C-II narcotic count discrepancy
An report of the wrong medication dispensed to a patient
A report of a ‘good catch’ of an error before it reached the patient
A report of an expired product received from the wholesaler

60. Answer: Question 2
In which of the following situations would conducting a Root Cause Analysis (RCA) be most appropriate?
A report for a C-II narcotic count discrepancy
An report of the wrong medication dispensed to a patient
A report of a ‘good catch’ of an error before it reached the patient
A report of an expired product received from the wholesaler

61. Question 3
Which of the following is not consistent with an organizational Culture of Safety?
Demonstrated commitment to proactively seek safety solutions
Employees reporting unsafe conditions without fear of retribution
Commitment by all employees to address system vulnerabilities
RCA revealing hazards ignored due to fear of intimidation

62. Answer: Question 3
Which of the following is not consistent with an organizational Culture of Safety?
Demonstrated commitment to proactively seek safety solutions
Employees reporting unsafe conditions without fear of retribution
Commitment by all employees to address system vulnerabilities
RCA revealing hazards ignored due to fear of intimidation