Medical Error Prevention and Root Cause Analysis ________________________________________________
copy suite, radiology department) [17]. Based upon these find- ings, it is clear that direct communication among healthcare providers is key to preventing operative and postoperative complications. Healthcare facilities should provide more staff education regarding preventative measures, and healthcare providers can do their part by engaging in a healthy and mutual respect for all of the members of the healthcare team [17]. MEDICATION ERRORS Unquestionably, medication errors are one of the most com- mon causes of avoidable harm to patients. These errors may occur at any of these critical points: when ordered or prescribed by a physician; during documentation; while transcribing; when dispensed by a pharmacist; when administered by a nurse; or during monitoring. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as [20]: 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. Such events may be related to professional practice, healthcare products, procedures, and systems, including pre- scribing: order communication; product labeling; packaging, and nomenclature; compounding; dis- pensing; distribution; administration; education; monitoring; and use. It has been estimated that up to 50% of medication errors are caused by a provider writing the wrong medication, the wrong route or dose, or the wrong frequency, and nearly 75% of medication errors have been attributed to distraction of the care provider [24]. In addition, a number of medication errors can be linked to the prescriber who continually uses potentially dangerous abbreviations and dose expressions. Despite repeated warnings by the Institute for Safe Medica- tion Practices about the dangers associated with using certain abbreviations when prescribing medications, this practice continues. To eliminate this factor, there are fairly simple steps that can eliminate much confusion. Prescribers should [21]: • Avoid the use of the symbol “U” or “u” but rather spell “units” when ordering drugs, such as insulin. • Spell out medication names completely rather than using abbreviations and acronyms. • Avoid using abbreviations for “daily” (QD), “every other day” (QOD), or “four times daily” (QID), which are easily confused. • Use leading zeros before a decimal point (e.g., 0.2 mg instead of .2 mg), and do not use trailing zeros (e.g., 2 mg instead of 2.0 mg). • Write out “morphine sulfate” and “magnesium sulfate” instead of using the abbreviations (MS, MSO 4 , MgSO 4 ).
The Institute for Safe Medication Practices publishes a list of error-prone abbreviations, symbols, and dose designations online at https://www.ismp.org/recommendations/error- prone-abbreviations-list. Other factors contributing to prescriber errors are illegible or confusing handwriting and, a frequently cited cause of many adverse and sentinel events, the failure of healthcare providers to assess risk and prevent errors. Addressing illegibility may include developing appropriate policies and procedures, track- ing and trending patterns, and evaluating results through peer review committees. Improving communication might include developing protocols for the use of verbal orders to assure that those from an onsite practitioner would be limited to an emergency situation only. No verbal orders should be taken for certain medications, such as for chemotherapy, and all verbal orders should be repeated for clarification and, when- ever possible, reiterated to a third person. Another method of improving communication might involve reviewing the hospital formulary in collaboration with the Pharmacy and Therapeutics Committee of the medical staff to limit, where appropriate, the number of therapeutically and generically equivalent products [22]. It has been estimated that between 0.2% and 10% of prescrip- tions are dispensed incorrectly [23]. The three most common dispensing errors are: dispensing an incorrect medication, dosage strength, or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications [24]. Safe medication dispensing practices may include a number of risk reduction strategies to reduce the incidence of errors that may cause harm to patients [22; 25; 54; 61]: • Ensure that appropriate and current drug reference texts and/or online resources are immediately available to pharmacy personnel. • Ensure that essential patient information, such as allergies, age, weight, current diagnoses, pertinent lab values, and current medication regimen, is available to the pharmacist prior to the dispensing of a new medication order. • Require clarification of any order that is incomplete, illegible, or otherwise questionable using an established process for resolving questions. • Whenever possible, dispense dosage units in a ready-to- administer form. • Dispense single-dose vials and ampoules rather than multidose vials. • Select oral rather than injectable routes, when possible. • Require that a pharmacist double-check all mathematical calculations for neonatal and pediatric dilutions, parenteral nutrition solutions, and other compounded pharmaceutical products.
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MDFL0626
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