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Tips to Prevent Medication Errors
Charlene DiNobile, Lisa Reed
Publish Date: September 4, 2008   |  Tags:   Patient Safety

The most common type of medical error? Those associated with medications, says the Joint Commission in an April 2008 Sentinel Event Alert. To prevent medication errors at your facility, you must recognize the risks, keep your policies up to date with the latest recommendations and conduct random audits to ensure those policies are being followed.

Acknowledge the risks. In the past, illegible penmanship and unfamiliar abbreviations were two of the biggest culprits leading to medication errors. With the onset of new technology, errors associated with labeling, packaging, product nomenclature and order communication have become more common, according to "A Systematic Approach to Preventing Medication Errors" (June 2003 U.S. Pharmacist), which identified several other causes of medication errors, including failed communication, poor drug distribution, complex or poorly designed technology, dose miscalculations and stressful workplace conditions. Even bar-code technology is no cure-all for preventable adverse events from medication errors (see "Study Finds Flaws in Medication Bar-code Systems" on page 34).

If your facility treats lots of pediatric patients, the risks may be even greater. Children are more prone to medication errors because most medications are formulated and packaged for adults, says the Joint Commission. Any pediatrician or pediatric nurse will remind you that a child isn't just a small adult, particularly when it comes to performing surgery and administering medications. Have special policies, safeguards and staff members in place to handle pediatric medication needs. The Joint Commission suggests the following precautions:

  • weigh pediatric patients and document their weight in kilograms;
  • include the calculated dose in prescriptions for children;
  • separate adult doses from child doses in your automated dispensing machines and cabinet drawers; and
  • communicate pediatric medication information, including how it should be administered and potential side effects, both verbally and in writing to the child and his parents or guardians. Have them repeat the information back to you and encourage them to ask questions.

Review your policy. With the Joint Commission's recent release of its Patient Safety Goals for 2009, which include new medication safety requirements, now is the perfect time to review and, if necessary, revise your facility's policies for administering medications. According to Joint Commission guidelines, your policies should:

  • standardize and identify medications and processes effectively;
  • reflect appropriate pharmacy oversight; and
  • set uniform procedures and monitoring for consistency.

The Joint Commission also has a handy "Do Not Use" list of abbreviations, symbols and acronyms (www.jointcommission.org/PatientSafety/DoNotUseList) that you can use to avoid the kind of confusion that leads to medication errors. In addition, consult AORN's Standards and Recommended Practices, which refers to the five "rights" of medication administration: right patient, right medication, right dose, right time and right route.

Study Finds Flaws in Medication Bar-code Systems

Bar-code technology for medication administration is designed to reduce errors by helping caregivers match the patient to the correct drug and dosage he is scheduled to receive. But in the fast-paced, often-hectic, hospital setting, what works in theory doesn't always work in practice.

That's what researchers at the University of Pennsylvania School of Medicine found when they studied the use of bar-coded medication administration systems in five U.S. hospitals. Although bar codes do help prevent medication errors when they function properly, flaws in the technology and implementation of the systems can actually increase the risk of medication errors, the researchers conclude in a study published in the Journal of the American Medical Informatics Association.

The research team, led by Ross Koppel, PhD, found that nurses would sometimes deviate from proper bar-code usage and safety protocols when presented with technical difficulties (unreadable or missing bar codes, dead batteries, dropped wireless connections) or environmental, organizational or patient-related constraints. The researchers identified 15 types of bar-code workarounds in three categories: omitted steps, incorrect sequence and unauthorized steps. While these deviations were often necessary to ensure medications were administered on time, they also increased the risk of potential errors, such as wrongly administered drugs and doses, the study shows. Researchers also found that "although staff frequently blame the technology???, a significant source of difficulties is not malfunctioning technology but rather barriers generated by how the technology is designed for and used in organizations, and how staff respond to its use."

To improve the efficacy of medication bar-code systems and reduce the need for workarounds, the researchers recommend a holistic and ongoing evaluation of the technology and its applications in real-world clinical settings. "Reiterating rules or enacting more rules may not reduce workarounds," write the study authors. "Instead, repeated examinations and corrections of [the systems'] actual uses are needed to optimize their role in preventing medication errors."

— Irene Tsikitas

To view the full text of the study, go to www.jamia.org/cgi/content/full/15/4/408

Medication Safety Audit Tool




Delivering Medication to the Sterile Field

The circulator confirms medication listed on the physician's preference card with the surgeon before delivering it to the sterile field.

The circulator verbally and visually shows the scrub person the medication before delivering it to the sterile field.

Only one medication is delivered at a time.

Medications are delivered aseptically.

Managing Medications on the Sterile Field

The scrub person labels the medication container on the sterile field just before receiving the medication from the circulator.

Scrub person verbally confirms the medication name, strength, dosage and expiration date to the circulating nurse.

Scrub person verifies that the label on both the medication container and delivery device has the medication name, strength and concentration.

When passing the medication, the scrub person verbally and visually confirms the name, dosage and strength to the surgeon.

All solutions — including medications, contrast dyes, irrigating solutions and stains — are labeled.

Scrub person keeps track of the amount of medication used.


Patient allergies are documented.

The scrub person notifies the circulator how much medication/irrigation solution is used during the procedure.

The circulator documents the name of the medication, strength, route and amount on the OR record.

Only approved abbreviations are used.

Date and time of audit: ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Room #: ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Monitor your meds. Conduct periodic, random audits of your perioperative staff to ensure everyone has a clear understanding of the medications you dispense and your policies governing them. Use the "Medication Safety Audit Tool" on page 35 as a guide, paying close attention to the following:

  • Communication. Staff should communicate both the type and amount of medication they're dispensing to the sterile field. No one should administer solutions they haven't personally verified.
  • Allergies. The circulator should identify the patient, check for medication allergies and document and communicate any allergies to all surgical team members.
  • Labeling. Look around the OR: Are any solutions lacking a label? If so, they must be discarded. Many solutions look the same and can be easily mistaken. Even if there's only one solution on the field, it must be labeled.
  • Staffing and shift changes. If there's a change of personnel in the OR, the circulator must show the relief staff the name, strength and expiration date of the medication on the field. If it's a standard medication that a surgeon uses, it should be cross-referenced with the physician's order.

To view the Joint Commission's "Do Not Use" list of abbreviations, go to www.jointcommission.org/PatientSafety/DoNotUseList To view the Joint Commission's 2009 National Patient Safety Goals, go to www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals