Executive Summary Checklist
Medication errors (wrong drug, wrong dose, wrong patient or route of administration) are a major cause of inpatient morbidity and mortality. An effective program to reduce medication errors will require an implementation plan to complete the following actionable steps:
- Hospital leadership must understand the medication safety gaps in their own system, and be committed to a comprehensive approach to close those gaps.
- Create a multidisciplinary team, including physicians, nurses, pharmacists, and information technology personnel to lead the project.
- Implement systematic protocols for medication administration, featuring checklists for writing and filling prescriptions, drug administration, and transition of care, as well as other quality assurance tools. These tools will include:
- Installing the latest safety technology to prevent medication errors, such as the BD™ Medication Management System and First Databank FDB MedKnowledge™ system
- Use barcoding drug identification in the medication administration process.
- Check patient’s allergy profile before prescribing medication.
- Ensure appropriate training and safe operation of automated infusion technologies.
- Distinguish “look-alike, sound-alike” medications by labeling design and storage.
- Implement a system for follow-up to ensure medication adherence.
- Implement technology that standardizes Computerized Physician Order Entry (CPOE), reporting systems and quality assurance reports to audit compliance with safe drug administration practices.
- Practice the Five Patient Rights on Medications: right patient, right drug, right dose, right route, and right time of administration. All care providers should use this simple checklist.
- Provide education of all hospital personnel in the principles above. Monitor the effectiveness of this education at regular intervals.
- Review monitoring results at medical staff meetings and educational sessions as a part of Continuous Quality Improvement (CQI).
Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.