Medical Error Prevention and Root Cause Analysis ________________________________________________
• 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. • 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.
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