Medication Error Prevention: Systems and Safe Practices

What Is a Medication Error?

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.

Errors can occur at any stage of the medication-use process:

• Prescribing
• Transcribing and order entry
• Dispensing
• Administering
• Monitoring

NCC MERP also publishes an Index for Categorizing Medication Errors that classifies events from Category A (circumstances with the capacity to cause error) through Category I (an error that may have contributed to or resulted in death). Near misses that do not reach the patient are valuable learning opportunities.

High-Alert Medications

The Institute for Safe Medication Practices (ISMP) defines high-alert medications as drugs that bear a heightened risk of causing significant patient harm when used in error. Errors with these drugs are not necessarily more common, but the consequences can be more severe. ISMP maintains lists for acute care, community and ambulatory care, and long-term care settings. Examples include:

• Insulin (all formulations)
• Opioids
• Anticoagulants, such as heparin and warfarin
• Concentrated electrolytes, such as concentrated potassium chloride for injection
• Neuromuscular blocking agents
• Antineoplastic (chemotherapy) agents

Recommended safeguards for high-alert medications include standardized order sets and concentrations, limiting access, using smart infusion pumps with dose error-reduction software, auxiliary labels, and independent double checks for selected high-risk processes.

Look-Alike/Sound-Alike Names and Error-Prone Abbreviations

ISMP and FDA have long identified look-alike/sound-alike (LASA) drug names as a source of error, for example hydroxyzine and hydralazine. Strategies include tall man lettering (such as hydrOXYzine and hydrALAZINE), including the indication on prescriptions, storing LASA products apart, and using barcode verification.

The Joint Commission's Do Not Use list and ISMP's List of Error-Prone Abbreviations, Symbols, and Dose Designations address dangerous notation:

• Write unit instead of U, which can be misread as 0 or 4.
• Write International Unit instead of IU.
• Write daily and every other day instead of Q.D. and Q.O.D.
• Never use a trailing zero (write 1 mg, not 1.0 mg).
• Always use a leading zero (write 0.5 mg, not .5 mg).
• Write morphine sulfate or magnesium sulfate instead of MS, MSO4, or MgSO4.

Safe Administration Practices

Commonly taught checks, often called the rights of medication administration, include the right patient, drug, dose, route, and time, along with right documentation. These checks are important but cannot prevent every error on their own, because they depend on individual vigilance.

Key practices supported by The Joint Commission National Patient Safety Goals and ISMP include:

• Using at least two patient identifiers, such as name and date of birth, never the room number.
• Using barcode medication administration as designed, without workarounds.
• Performing medication reconciliation at transitions of care.
• Labeling all medications and containers, including syringes, on and off the sterile field.
• Minimizing interruptions during medication preparation.
• Using read-back for verbal and telephone orders.
• Educating patients with teach-back so they understand what they are taking and why.

System-Level Strategies

Most errors result from system weaknesses rather than individual carelessness. ISMP describes a hierarchy of risk-reduction strategies, from most to least effective:

• Forcing functions and constraints, such as oral syringes that cannot connect to IV lines.
• Automation and computerization, such as computerized prescriber order entry with clinical decision support, and barcode scanning.
• Simplification and standardization, such as standard concentrations and order sets.
• Reminders, checklists, and double checks.
• Rules and policies.
• Education and information.

Stronger strategies change the system so errors are harder to make. Weaker strategies rely on memory and attention, which are vulnerable to fatigue and distraction. Effective programs combine several levels.

Reporting and Just Culture

Reporting errors and near misses allows organizations to identify hazards and fix systems. Report internally according to your organization's policy. External voluntary programs include the ISMP National Medication Errors Reporting Program (ISMP MERP) and FDA's MedWatch program for adverse events and product problems.

A just culture distinguishes among:

• Human error: an inadvertent slip or lapse, best addressed by improving systems and supporting the individual.
• At-risk behavior: a choice where risk is not recognized or is believed justified, such as a workaround, best addressed by coaching and removing incentives for the shortcut.
• Reckless behavior: conscious disregard of a substantial and unjustifiable risk, which may warrant disciplinary action.

When an error reaches a patient, follow your organization's policy for immediate patient assessment, notifying the prescriber, documentation, and disclosure.

Special Risk Situations

Certain situations deserve extra attention:

• Pediatric patients: weight-based dosing increases the risk of calculation errors. Weigh patients in kilograms, document weight in kilograms only, and use standardized concentrations and oral syringes for liquid medications.
• Older adults: polypharmacy, changes in kidney and liver function, and cognitive changes increase risk. The American Geriatrics Society Beers Criteria identify potentially inappropriate medications for older adults.
• Transitions of care: admission, transfer, and discharge are points where omissions and duplications commonly occur. Thorough medication reconciliation, including over-the-counter products and supplements, reduces these errors.
• Intravenous infusions: use smart pumps with drug libraries, trace lines from the patient to the source before connecting, and verify pump programming.
• Look-alike packaging: read the label three times, when retrieving, preparing, and before administering, rather than relying on package color or shape.

Patients are partners in safety. Encourage them to keep an up-to-date medication list, ask questions when a medication looks different, and speak up if something seems wrong.