Regular use of medication is widespread across the United States. According to a national survey, 81% of respondents had taken some form of medication the previous week, and 50% took at least one prescription medication.1 With such prevalent use, it’s easy to see how patients can get confused about what they’re taking, and overworked healthcare professionals can make mistakes.
Consider the nurse who was convicted of medically negligent homicide and faced a potential sentence of up to eight years imprisonment. It’s no wonder we’re seeing fear around reporting errors, not to mention the never-ending distractions that create opportunities for errors at every spot along the continuum of patient care.
In the fast-paced world of hospital pharmacy, where every prescription carries a weighty responsibility, staying vigilant against medication errors is a constant challenge. From near misses and unfortunate oversights to more serious cases of negligence, providing excellent patient care demands an unwavering commitment to safety.
What are Medication Errors?
Nailing down what constitutes a medication error can be tricky when you consider all the variables that health systems and health care providers face when caring for patients.
However, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) has defined 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”
Effects of Medication Errors
Medication errors can potentially cause patients to experience adverse reactions, worsened medical conditions, or even fatalities. In the US alone, it’s estimated that 7,000 to 9,000 patients die from a medication error. And over one-third of patients have reported at least one medication error when admitted to the hospital. Ninety-one percent of those errors are considered clinically significant. These are serious challenges that must be overcome to improve patient safety.
Beyond the immediate impact on the patient, health professionals involved in the errors may suffer profound emotional distress, damage to their professional reputation, and legal consequences, not to mention a breach of public trust.
And the healthcare system and community it serves bear the financial burden of treating the consequences of these errors. It’s estimated that the cost of care from medication-related errors surpasses $40 billion every year.
5 Strategies to Prevent Medication Errors
Create a Culture of Safety and a System for Reporting Errors
If healthcare professionals are worried that medical mistakes will be criminalized and nurses will be scapegoats, it makes sense that there will be fear around reporting errors.
It’s imperative that hospital administrators discuss how to create a culture of safety, starting with a top-down approach that fosters a blame-free environment both on the floor and in the hospital pharmacy as well. They should be asking themselves what safeguards do we have in place, and how do we make it safe for our people to admit when an error has happened?
There are a wide variety of systems, technologies, checks and balances to help prevent medication mistakes. But any tools or strategy should always be implemented in the larger context of an overall culture of safety. That includes the “Five Rights” of medication administration.
The entire process involves leadership communication that emphasizes the importance of reporting errors and near misses without fear of retribution. Regular safety assessments and root cause analyses should be conducted to identify areas for improvement, and routine evaluations of processes and protocols should be performed.
Errors are opportunities for learning and improvement. By fostering a culture that views errors as stepping stones to enhancement rather than as failures, hospital pharmacies create an environment where staff are proactive in identifying and addressing potential pitfalls.
Minimize Distractions and Interruptions
Multi-tasking comes with the job in any healthcare profession, which opens the door for errors to occur and patients to be harmed. One study found that healthcare providers can be distracted or interrupted as often as once every two minutes.
Referencing recent research on distractions and interruptions during the medication-use process, the Institute for Safe Medication Practices (IMSP) offers several strategies on how to prevent medication errors. These include defining critical tasks where there should be no interruptions, limiting alerts, alarms and noise, developing a checklist for lengthy or complicated tasks, and designating a time to address non-urgent questions.
A key preventive strategy is to identify and improve the systems and processes around the most common distractions. For example, put ADCs in areas that have limited foot traffic or even establish a quiet zone around the ADC. Precautions like this help to limit the risk that the wrong medication could be stocked or taken out.
Utilize Data from Safety Audits
We all know that medication safety audits serve as proactive measures to identify potential vulnerabilities in the system. By systematically reviewing processes and protocols, hospital pharmacies can detect and rectify issues before they lead to errors. But how often do healthcare administrators actually use the data from these audits or other sources?
It’s not uncommon to sit in meetings where people are regurgitating data and then nothing happens. What do we do with all this important information that someone so painstakingly spent hours collecting? Who is designated to analyze it, to look at the errors found in an audit and then develop a plan of action to address it?
Designate a person or team to review the data and identify larger systemic issues. Have them assess compliance with established protocols, evaluate the effectiveness of implemented safety measures, and then work together to put a plan of action in place.
Manage Agency Nurses and Invest in Staff Training and Education
A lot of medication errors, unfortunately, come from agency nurses who aren’t familiar with the practices or technology that a hospital is using. They’re on site for, say, a 13-week assignment and have to quickly learn and adapt to new technology systems. It’s no surprise that errors happen when someone new comes into an organization where they’re unfamiliar with the practices.
Putting in place very clear guidelines surrounding the system can help address this issue, but what can make an even greater impact is to start investing in existing nurses and hiring more full-time nursing staff.
The investment in staff training begins with the development of ongoing programs that emphasize continuous learning and staying updated on medication safety best practices. This may include regular workshops, seminars, and online modules to ensure that all clinical staff remain up to date on the latest advancements in the field.
Beyond developing technical skills, fostering a culture of open communication is equally important. Implement regular team-building exercises and forums where staff are encouraged to share their experiences, report errors, and discuss near misses. Continuous education ensures that staff are equipped with the latest knowledge, while open communication builds a culture of accountability and improvement.
Use Technology to Your Advantage
Technology is available at every stage of care, from the pharmacy to the patient’s bedside.
Barcoding aids everyone from the central pharmacy to the provider administering the med. Automated dispensing cabinets are equipped with barcode reading so there’s less opportunity for errors on both the stocking end and when nurses pull the meds.
It’s ideal for addressing the bias of the mind and eye. With look-alike and sound-alike drugs, it’s easy for human error to come into play and misread a label. Barcoding helps to assist with that type of bias as well as double check the med, validate it and trace it.
In the IV room, robotic technology can help measure volumetrics and gravimetrics, taking into account the specific gravity or density of a solution so that it knows the exact quantity being pulled, using chemistry to understand and validate what the density of the IV should be.
When a med needs to be drawn up manually, a modified document camera with a scale can help track it. A snapshot is taken at each stage of the preparation so that the pharmacist can see everything that needs to be done and is being done. Then a picture is taken of the final container and the barcode is scanned. It all works together to form a system of checks and balances to protect both the healthcare provider and the patient.
Radio Frequency Infrared Devices, or RFIDs, emit a low level signal similar to Apple’s AirTags. Hospitals can be hectic places, especially in the ER, OR or ICU. Carts have to be refilled, jump bags need to be stocked for transportation, and materials have to be ready and on hand for critical care.
Safe and effective care has to be provided, which means the right meds need to be readily available. Not only do providers have to find the needle in the haystack, but they often have to find it while they’re spinning around in the chaos. The RFID helps you find the meds quickly and helps eliminate some of the human bias and confusion.
By implementing these technologies and all of the strategies discussed above, hospital pharmacies can create an environment where medication errors are minimized and patient safety is prioritized at every step of the process.
- Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA.Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA. 2002;287(3):337-344
About the Authors
Dr. Jennifer Allen, Area Clinical Manager
Dr. Jennifer Allen joined the CompleteRx team in 2017 and is the Area Clinical Manager. In her role, she works closely with medical staff to coordinate Antimicrobial Stewardship Programs, Pain Management Programs, Pharmacy and Therapeutics Committee meetings, formulary management, staff education, performance improvement projects, medication use evaluations (MUE) and develops clinical tools for health systems under the direction of the Director of Clinical Services. Jennifer has served as the Residency Program Director for an ASHP accredited program and precepts the advanced experiential clinical administration pharmacy rotation.
With more than 15 years of hospital clinical pharmacy experience, Jennifer previously served as a Clinical Pharmacy Manager in an 11-hospital health system prior to joining the CompleteRx team. She was responsible for growing the clinical pharmacy program as the general clinical and infectious disease pharmacist. Jennifer also developed staff training competencies, precepted pharmacy students, and ensured compliance with Joint Commission standards and regulatory compliance.
Jennifer received her Pharm. D. from Mercer University in 2008 and started her career as a licensed pharmacist in Georgia. She currently maintains licensure in Georgia. Jennifer has received several safety awards including a pharmacy-nursing joint project on Medication Reconciliation, a pilot program that was expanded to the entire health system as well as two Team Covenant awards with CompleteRx. Jennifer is certified in Antimicrobial Stewardship through MAD-ID (2012), the Society of Infectious Disease Pharmacists (2019), and is a Board-Certified Pharmacotherapy Specialist (2018).
Jennifer has also been published in Managed Care Executive on current topics such as biosimilars, long-acting injectable antipsychotics, and pipeline vaccines.
Dana Fox, Pharm. D., Director of Quality and Compliance
Dr. Dana Fox joined CompleteRx in 2003 and is the Director of Quality and Compliance. In his role, Dana oversees the compliance assessments and solutions and the quality improvement solutions – such as pharmacy implementations and processes changes – to meet the needs of hospitals and pharmacists across the country.
Dana previously served as Director of Pharmacy for a health system in Atlanta, Georgia and has over 22 years of experience in hospital pharmacy management and operations including operational and process improvements, implementation of automation, 340B, pharmaceutical purchasing and medication safety.
Dana received his Pharm.D. from University of Illinois at Chicago and completed a two-year health system pharmacy administration degree at University of Wisconsin Health. He has completed Six Sigma Green Belt training with Purdue University.