How “Blocking and Tackling” Can Prevent Pharmacy Medication Errors

Various pills in small container.

Recent high-profile events have once again revealed the vital role basic hospital processes and procedures play in reducing medication errors. While current discussions focus on neuromuscular blockers, all medications and their handling should be part of this conversation.

It’s not enough to simply remove vecuronium from automated dispensing cabinets in all but the most essential departments. The fact is that humans make mistakes, especially in understaffed, high-stress environments like a hospital.

For healthcare organizations to reduce medication errors, we must study the systems we rely upon and ensure that every step in every process supports patient safety.

Any thorough review of your medication management practices should look at the stages involved in delivering drugs to a patient. This includes:

  • Selection and procurement of medications
  • Medication storage
  • Ordering and transcribing
  • Preparing and dispensing
  • Administration and monitoring

Ways To Reduce Hospital Pharmacy Medication Errors

Here are just a few of the basic actions your hospital should follow to mitigate the number of medication errors.

  1. Review information management systems

Look at how you have drugs categorized. Any request for a high-alert medication should deliver a prominent on-screen reminder warning of the dangers of this drug. Remember, your organization decided the medication was high-alert, so what extra steps are you taking to reduce known risks?

Staff also should be able to search for drugs by generic and brand names across all your systems. This helps prevent the wrong drugs being selected from an alphabetical list of medications due to lack of familiarity with similar names.

The Institute for Safe Medication Practices issued an excellent list of recommendations for steps to improve patient safety during the administering of all drugs, not just high-alert medications. Many of those recommendations focus on the technology we all use every day, including electronic medical records (EMRs) and automated dispensing cabinets (ADCs). Read Safety Enhancements Every Hospital Must Consider in Wake of Another Tragic Neuromuscular Blocker Event.

  1. Evaluate drug-related protocols

Assess the protocols that govern under what circumstances a nurse can override the ADC. Do your ADCs adequately limit a staff member’s ability to override medication removal?

Current best practice limits override removal to urgent or emergent situations (i.e., when waiting for a pharmacist to review the order could cause patient harm).

If an override is allowed, does your system require a second nurse to witness and verify the correct medication and dose has been removed? Using “forcing functions” such as these limit everyone’s ability to issue unnecessary overrides.

Protocols should also clearly outline how a patient should be monitored after receiving a medication.

  1. Make use of packaging and labels

Look-alike, sound-alike drugs remain a constant issue that requires attention.

However, something as simple as purchasing the same agents from different manufacturers would mean the products look different because of the packaging.  This can aid staff in selecting the appropriate product.

For neuromuscular blockers specifically, it is recommended to individually store doses in baggies with a big, red warning label, or to shrink-wrap the bottle. The extra visual clues and physical exertion required to open and administer a high-alert drug can help prevent mistakes.

  1. Analyze all overrides regularly

Daily, your organization should run a report and review the overrides that occur. Such an analysis can expose systematic problems that can be fixed. These include removing a medication for a non-urgent situation, or verification of a provider order in the chart for the medication.

The Joint Commission also is paying closer attention to overrides during its surveys, having issued new guidelines in January 2018.

Any severe error should cause the organization to review the entire medication management process and look for gaps in the safety system. Or, even better, conduct a systematic technique for failure analysis to mitigate the chance for the error to even occur.

By tightening our processes, we can all contribute to greater patient safety through fewer medication errors.


By Ken Maxik, MBA, MBB, FACHE, Director Patient Safety and Pharmacy Compliance for CompleteRx.

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