Challenge 3A Medication Errors

Medication Errors

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.

Parent Challenge

  1. Challenge 3: Medications