Nearly 5 years ago, 2-year-old Emily Jerry died at a Cleveland hospital where she'd been undergoing treatment for a tumor in her abdomen, but it wasn't the cancer that killed her. While undergoing her final round of chemotherapy, a pharmacy technician at the hospital made an error compounding saline solution and ended up mixing Emily's chemotherapy drug with 26 times the normal concentration of saline. The mistake proved fatal, and Emily died 3 days after receiving the medication.

This case was shocking, not only because a little girl died, but also because the culprit wasn't the cancer (which was curable) or her potent chemotherapy drugs, but the diluent used in her IV bag. Many people don't realize or don't believe that diluents can be harmful. In fact only about 3% of medication errors are harmful. But as the Emily Jerry case illustrates, failing to properly check that the right drug and right dose are administered to the right patient at the right time can have devastating consequences, even when you're dealing with something as seemingly harmless as the amount of sodium chloride in an IV bag.

No matter how routine the order or the drug, it's absolutely vital that your physicians, nurses and pharmacy personnel follow formalized, thorough protocols when giving and receiving drug orders and administering medications to patients. We perform complex tasks every day, and we need to get them right every time.

Root out risk factors
Don't assume that "it can't happen" at your facility, because the medication safety literature is filled with examples of things that "can't happen," but did. When assessing your facility's risk, identify and remove risk factors for error. Focus on 3 key areas: your formulary, storage and communication.

• Formulary. Run through your facility's drug formulary and examine each drug, one at a time, considering what could go wrong with each. For example, we know there is very little margin for error with opioids, but other drugs may be relatively less likely to harm a patient if administered correctly. Make sure you do an honest assessment of the worst-case scenario for each drug. Also check to see if you have any drugs with look-alike/sound-alike names. These assessments will help you develop safeguards to prevent errors, such as stocking different versions of drugs to avoid look-alike/sound-alike mixups, storing such drugs far away from each other, ordering standardized strengths and vial sizes, or purchasing already compounded solutions instead of compounding them on-site.
• Storage. How you store drugs can have a huge impact on your potential for medication errors. Never store look-alike/sound-alike drugs next to each other. Avoid stocking multiple strengths of the same drug, and if that's unavoidable, be sure to clearly label bins, vials and other storage containers with the drug name and strength. Purchasing products that look different in appearance and have distinct labels can help ensure that staff don't put supplies in the wrong place by mistake. Follow all regulatory guidelines for the proper storage of narcotics and other controlled substances; security measures help prevent these drugs from falling into the wrong hands and from being erroneously administered to patients.

Once you have a good system down, stay with it. When people are used to getting a particular type of drug out of a particular bin, confirmation bias sets in, and they're going to continue to think the bin holds that drug even after you change it. Consistency of storage practices helps remove these types of errors from the equation. When you do need to make a change, make sure it's communicated effectively to all staff members who come into contact with drug supplies.

• Communication. Often cited as the No. 1 cause of medication errors, breakdowns in communication among physicians, nurses, pharmacists, techs and patients and their families can mean the difference between a little girl getting a normal dose of 0.9% saline solution and a fatal dose of 23.4% saline solution, as in the Emily Jerry case. In medical errors, there can be disconnection between what is said and what is understood. For example the nurse might perceive, "I thought he said it was a new order," while the physician says, "I just said I was ordering a fentanyl patch that the patient was already on."

Many times, mistakes occur because of the informal nature of communication. To avoid mistakes, formalize and standardize the communication methods used at your facility to relay drug orders, hand off patients between caregivers and instruct patients and their family members about medications they'll need to take after they leave your facility. Use time outs and checklists, like the ones provided on page 68, to make sure you dot every "i," cross every "t" and verify every bit of information down to the last decimal point.

Most importantly, take the time to listen to one another. Don't assume the nurse, physician, pharmacist or patient knows what you're talking about. The person relaying medication information, whether it be a patient's history, drug orders or instructions for administration, should always wait until the person receiving the information reads it back and demonstrates that they understand.

When error strikes
If a medication error does occur at your facility, the best response is an honest one. After you've assessed the patient and prevented or treated any adverse effects, disclose the error to the patient, say you're sorry and explain how you're going to prevent it from happening again. In most cases, the error will not cause serious harm to the patient, and you'll find that patients generally appreciate your honesty and your efforts to do better next time. Also be sure to check with your state and local regulatory bodies; some require mandatory reporting of medication errors within a set period of time.