________________________________________________ Medical Error Prevention and Root Cause Analysis
• Create an environment for the dispensing area that minimizes distractions and interruptions, provides appropriate lighting, air conditioning, and air flow, safe noise levels, and includes ergonomic consideration of equipment, fixtures, and technology. • Require that a second pharmacist double-check the accuracy of order entry and dose calculations for all orders involving antineoplastic agents and other high- risk drugs dispensed by the pharmacy. • Enhance the awareness of look-alike and sound-alike medications, and use warning signs to help differentiate medications from one another, especially when confusion exists between or among strengths, similar looking labels, or similar sounding names. • Separate look-alike and sound-alike medications in pharmacy dispensing areas or consider repackaging or using different vendors. • Follow-up and periodically evaluate the need for continued drug therapy for individual patients. Once again, communication is likely the key to avoiding dispensing errors. Pharmacists should work closely with their staff to ensure that proper protocols are followed, and most importantly, when questions arise regarding a prescription, the pharmacist should take the time to contact the prescriber directly to obtain clarification. The healthcare provider who has the responsibility to adminis- ter a medication has the final opportunity to avoid a mistake. In most cases, particularly in inpatient settings, this respon- sibility falls to the nurse. Nurses are often taught in nursing school to review the five “rights” prior to administering any medication: the right patient is given the right drug in the right dose by the right route at the right time [26]. Medica- tion errors generally fall into four categories, which mimic these five “rights.” The first is the failure to follow procedural safeguards, such as ensuring that essential patient informa- tion, including allergies, age, weight, and current medication regimen, is available. The second is unfamiliarity with a drug. In one case, a jury determined that a nurse was negligent for giving a drug without having reviewed the literature, which stated that the necessary precautions for the administration of the drug required the specialized skill of an anesthesiologist. The third category of drug administration is failure to use the correct mode of administration. A nurse in Delaware was held liable for administering a medication by injection after an order had been written to change the route to oral. The final category involves failure to obtain clarification if an order is incomplete, illegible, or otherwise questionable. In a case tried in Louisiana, a nurse was held liable for administering a medication that a physician ordered, notwithstanding that the dose was excessive. The nurse’s administration of the drug led to the patient’s death [27].
In addition, healthcare facilities should implement appropriate guidelines, policies, and procedures to ensure safe medication administration practice. These policies should require that staff members who administer medications [24; 25; 54; 61]: • Are knowledgeable about the drug’s uses, precautions, contraindications, potential adverse reactions, interactions, and proper method of administration • Resolve questions prior to medication administration • Only administer medications that have been properly labeled with medication name, dose to be administered, dosage form, route, and expiration date • Utilize a standard medication administration time schedule and receive education on how and when to incorporate newly started medication orders safely into the standardized schedule • Have a second person verify a dosage calculation if a mathematical calculation of a dose is necessary • Receive adequate education on the operation and use of devices and equipment used for medication administration (for example, patient-controlled anesthesia pumps and other types of infusion pumps) • Have another person double-check infusion pump settings when critical, high-risk drugs are infused • Document all medications immediately after administration Finally, healthcare facilities should have proper quality assur- ance measures in place to monitor medication administration practices. Included among these would be protocols and guidelines for use with critical and problem-prone medications to help optimize therapies and minimize the possibility of adverse events and to integrate “triggers” to indicate the need for additional clinical monitoring [25]. It is important to note that the pediatric population is especially vulnerable to medication errors. When children are prescribed adult medications, care must be taken to adjust dosage accord- ing to weight, requiring the physician to use pediatric-specific calculations. Also, many healthcare settings are not trained to care for the pediatric patient. Intolerance due to physiologic immaturity is also a factor in adverse response to medications, and in many cases, this population cannot communicate their discomfort due to adverse reactions. Risk reduction strategies include standardizing and effectively identifying medications and processes for drug administration, ensuring pharmacy oversight, and using technology, such as medication dispensing programs, infusion pumps, and bar-coding, judiciously [28].
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