Medication Safety LOs

• Error of omission


  Neglecting to do something that should of been done
• Error of commision


  Doing something incorrectly
• What are the different stages a med error can occur

  Prescribing, Transcribing, Dispensing, Administration
• How to avoid med erros in prescribing stage

  1. Avoid unnecessary meds by adhering to conservative prescribing principles
  2. Use computerized provider order entry, especially when paired w/ clinical decision support systems
  3. Perform medication reconciliation at time of transitions in care
• How to avoid med errors in transcribing stage

  Use computerized provider order entry to eliminate handwriting errors
• How to avoid med errors in dispensing phase

  1. Utilize clinical pharmacists to oversee medication dispensing process
  2. Use “tall man” lettering and other strategies to minimize confusion between look/sound - alike meds
• How to avoid med errors in administration phase

  1. Adherence to “5 rights” of med safety: admin the right med, in the right dose, at the right time, by the right route, to the right patient
  2. Barcode medication administration to ensure meds given to the correct patient
  3. Minimize interruptions to allow nurses to admin meds safely
  4. Smart infusion pumps for IV infusions
  5. Pt education and revised medication labels to improve pt comprehension of admin instructions
• Role of FDA

  Ensuring that human and veterinary drugs, vaccines and other biological products and medical devices intended for human use are safe and effective
• When does the FDA require a medication guide be issued

  1. If certain info is necessary to prevent serious adverse effects
  2. When pt decision making should be informed by info about a known serious side effect
  3. When pt adherence to directions are essential for effectiveness
• Role of ISMP

  Nonprofit organization that focuses on medication error prevention and safe medication use

  • Have many useful resources on website, error reporting program, ISMP med safety newsletters, and educational programs
• What should be avoided when writing a prescription

  1. Use of trailing zeros instead of leading zeros
  2. 0.2 mg acceptable, .2 not acceptable; 5 mg acceptable, 5.0mg not acceptable
  3. “Use as directed” should be avoided
  4. Use of Q.D., instead write out daily