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How to Prevent Medication Errors

Discover practical strategies on how to prevent medication errors and ensure patient safety.
So, what is this error categorized? Right now, we have this example. So, we could start to, try to use the terms that we use, we given, from previous slides. This is an example a patient was sent to ER because the patient has taken alendronate without keeping her upper body up-straight after taking this medication for 30 minutes. We all know alendronate is a very good drug to prevent osteoporosis. But when patient take this medication, we all know that, we also will consult the patient they have to keep their upper body up-straight at least 30 minutes. Ok, so the patient got the damage on her esophagitis. Ok, so is it a drug-related problem? Yes. Ok, is it a medication error? Yes.
What type of medication errors? It’s administration error. Is it an adverse drug reaction? or adverse drug events? Or it is side effects? Ok, this case, we have to do something for the patient. So, it’s not a side effect because we need to do something. Side effect, you don’t need to do extensive management. Ok, so it’s an adverse event. That’s correct. Because it is an expected but well-known cause severe problem, so it’s adverse drug event.
Is it errors of commission or errors of omission? Obviously, this is errors of commission. Ok, so now we know how to use this terminology correctly. Ok, since we know these different terminologies, secondly, we want to introduce some preventing methodology for medication errors. Before we want to prevent the medication errors, we need to know some common reasons that causing medication error. For example, look-alike and sound-alike drugs? These are the drugs’ names, they look very similar in spelling or when we read the drugs’ names, they sound-alike. And also, they could have very similar logos because it was produced by same companies, so they have very similar logos on their packages. They could also category as look-alike products.
Secondly, it could be sloppy communication practices. For example, they illegible handwriting. The handwriting cause the problem in reading or a verbal order, is another type of sloppy communication practice. Thirdly incorrect transcription?
It could mean the pharmacies transcribe a wrong drug or the pharmacists make different intervention from the prescriber’s original intent. Verbal miscommunication, it could be sound-alike; it could be someone didn’t hear the drug’s name carefully. Distractions and overwork, this is very common in Taiwan,
pharmacists have to deal with a lot of orders, and need to deal with a lot of patient waiting. then When the numbers of patients increasing, probably, are errors also increased, too. Lastly, the poorly designed medication labels. And it could be made by the manufactures, and also could be made by the pharmacy because we repackage the medication. Then, we probably have the poorly designed labels. From IOM, the report, they recommend that there are several features could prevent medication errors. The first one, they recommend that we involve the patient in the medication used process.
If patient were involved, they could know how to take the medication and they could follow the instruction carefully, and also they know what the effect, positive, negative effect, they expected. Consumer-oriented medication resources should be made available to support patient self-management of their medication use. After we talk to patient, the patient, they go home and start taking medication by the selves. A lot of time, they may forget what we talk to them. So, if we have a consumer-oriented medication, for example, information sheet for them to take home, that will help them. Healthcare provider should have access to patient information and decision support tools, and technologies to enable them to be more active in monitoring and intervening.
This is also a type of communication when the healthcare professionals have more information, they could make a better decision.
Medication labeling needs to be improved along with methods for communicating medication information to consumers. And health Information technology must be improved to support the medication use process. The health information technology, we could have all the patients’ information, could be in electronic form. So, different healthcare professionals could read different discipline, they could read the information provided by different professionals at the same time. Also, the IOM reports recommend the pharmacies ease pharmacists doing following practice to prevent medication errors. Pharmacists must keep up with the medication literatures error information and take action for prevention.
The medication literatures error information could be very helpful because the error occurs at some other hospitals or other country also could occur in your own hospital or your country. Pharmacists should verify the accuracy of new prescription data, monitor for errors and near misses, make corrections as needed, and report errors to external reporting programs.
Patient identity should be verified using bar codes. Bar code is a very important tool to improve the accuracy and also improve the efficiency. And also, patient should be educated about ways to prevent medication errors. So, medication error prevention is also has patient’s role involved. Electronic prescribing should be used. So, this is another very important methodology to increase the accuracy and avoid the errors. Electronic prescribing could help the prescribing process and also it could decrease the transcribing errors.
Trivial warning to prescribers and pharmacists should be avoided in medication decision-support systems. Trivial warning means those warning are not so important, and it may not occur in patient’s body. But if the systems keep pumping these warning that could cause prescribers or pharmacists information fetch.

After understanding what medication errors are, the next step is to draft plans to resolve them. In this step, Chiang will discuss what are the various strategies pharmacists can utilize.


Common Causes for Medication Errors

  • Look-alike and sound-alike drugs
  • Errors in communication (verbal and written)
  • Distractions and overwork
  • Poorly designed medication labels

IOM recommendations

  • Involve patients to manage their own medication therapies
  • Increase accessibility to patient/drug information
  • Improve medication labels
  • Health information technology

Pharmacists should also:

  • Keep up with the medication literature.
  • Verify the accuracy of new prescription data.
  • Monitor for errors and near misses, make corrections as needed, and report errors to external reporting programs.
  • Make good use of barcodes.
  • Carry outpatient education.
  • Use electronic prescribing.
  • Optimize decision-support systems.

To learn more about the prevention of medication errors, check out this course: Good Pharmacy Practice: Pharmaceutical Services from Taipei Medical University.

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Good Pharmacy Practice: Pharmaceutical Services

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