Patient Safety in Medication Use

Medication errors and adverse drug events (ADE) occur at all phases of the medication use process. The suggestions below represent optimal practice in many settings, though their effective implementation may require a thorough operational and resource evaluation.

Practitioners

  1. Consider including the following information on all medication orders/prescriptions:
    a. Patient allergies
    b. Brief notation of purpose (e.g., for cough) when appropriate
    c. Generic name
    d. Dosage form
    e. Expected duration of therapy on all antimicrobial orders
    f. Calculated dose and the mg/kg dose are recorded on pediatric prescriptions
    g. Age when appropriate
    h. Weight when appropriate
  2. Avoid abbreviations including those for drug names (e.g., HCTZ) and Latin directions for use (e.g., TIW).
  3. Avoid the use of vague instructions such as "take as directed" or "take/use as needed" as the sole direction for use.
  4. Provide written information on medications.
  5. Receive periodic education regarding new drugs or revised drug dosing.
  6. Work with your pharmacists to maintain updated lists of sound-alike drugs to avoid errors and to function as a cue to clarify spelling or specification of intended use.

Pharmacists

  1. Receive periodic education regarding new drugs or revised drug dosing.
  2. Read back all verbal (telephone) orders to prescriber to assure accuracy and request:
    a. Information to confirm the patient's identification (e.g., name, birth date, address)
    b. Patient's weight
    c. Co-morbid disease states
    d. Allergies
  3. Consider using basket system to keep the original order, prescription container and stock bottle together throughout the whole fulfillment and dispensing process.
  4. Work with your practitioners to maintain updated lists of sound-alike drugs to avoid errors and to function as a cue to clarify spelling or specification of intended use.
  5. Adopt procedures that minimize confusion with look-alike/sounds-alike drugs. Example: Look-alike drugs are stored separately or a differentiating label is added.
  6. Use barcodes throughout the medication use process to ensure that the right drug at the right dose and the right route gets to the right patient at the right time.
  7. Implement "multiple sets of eyes" in the dispensing process.
  8. Include both brand and generic names on all prescription labels.
  9. Provide specialized packaging and labeling to the elderly, individuals with disabilities and other special patient populations.
  10. Provide patients with a phone or mail alert before automatic refills are dispensed.
  11. Offer patient a call-back option for more in-depth counseling.
  12. Offer educational and reference materials that facilitate counseling of non-English speaking patients, individuals with disabilities and other populations with special needs.
  13. Document patient counseling and interventions in a format that promotes easy access for review and subsequent dispensing.
  14. Counsel patients about general principles or strategies they can use to protect themselves from medication errors and adverse drug events. For more information, see Tips on Preventing Medical Errors in Children.
  15. Provide the patient with written information on medications.

Source: "Maximizing Patient Safety in the Medication Use Process" by Wisconsin Patient Safety Institute, Inc.

For more links to organizations and activities addressing medication safety, please go to www.wapatientsafety.org.

For tools and techniques of improved medication use, please go to http://www.aahp.org/content/navigationmenu/medcollab/medcollab.htm

For ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations go to http://www.ismp.org/Tools/abbreviationslist.pdf