Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Medication Safety-High Priority

R. Peter Iafrate, Pharm.D.  Director of Pharmacy, Shands AGH
  4-1-2   Efforts to reduce adverse drug events have steadily intensified over the last several years. Continuing high profile cases such as the 3 infant deaths at an Indianapolis hospital last September due to a heparin overdose and Institute of Medicine (IOM) studies such as the now famous 1999 “To Err is Human: Building a Safer Health System” and more recent July 2006 study “ Preventing Medication Errors” has propelled safety efforts by hospitals and regulatory agencies. The July 2006 IOM report, “Preventing Medication Errors”, conservatively estimates that 400,000 preventable drug-related injuries occur each year in hospitals resulting in $3.5 billion in extra medical costs. While errors can occur during any step of the medication process, (selection and procurement, storage, ordering and transcribing, preparing and dispensing and administration), the above study found that most errors occur during prescribing and administration.  Recommendations included improving communication between patients and health care providers by encouraging patients to take a more active role in their medication monitoring; utilizing information technology to reduce transcription errors, legibility issues and provide quick access to patient data such as allergies; and improve the labeling and packaging of medications to prevent errors associated with look-alike/ sound-alike drugs. JCAHO’s medication standards for hospitals cover all aspects of the medication use process and a brief overview of key areas are outlined below along with medication specific national patient safety goals. Since some of these are open to interpretation, please contact your hospital pharmacy department for specifics should you have questions.

 A) Patient specific information is readily accessible to those involved in the medication management system:

 1) Anyone who orders, dispenses or administers medications, must have access to the   following information when needed:

i) Patients age, sex, current medications

ii) Diagnosis, co-morbidities

iii) Lab values

iv) Allergies

v) Height and weight

vi) Pregnancy and lactation status

 B) Medications are properly and safely stored throughout the hospital

 1) Medications are stored under the proper conditions (i.e., refrigerated)

2) Controlled substances are properly secure; records are kept to detect any diversion

3) Look-a-like and sound-a-like drugs are identified and risks are minimized

4) Medications are provided in ready to use form (i.e., unit dose)

5) Periodic inspection of nursing units is conducted to ensure medications are stored properly

 C) Medication orders are written clearly and transcribed accurately

 1) Medication orders are legible, written as generic versus brand-name when possible

2) Somewhere in the patient’s chart, there must be an Indication for use for all medication

3) Hospital must have policies on all potential types of medication orders, (i.e., PRN orders, standing orders, hold orders, automatic stop orders, resume orders, range orders, taper orders, etc.)

4) Blanket orders (i.e., resume all previous medications) are not acceptable

 D) All prescriptions or medication orders are reviewed for appropriateness

 1) Before dispensing, removal from floor stock, or removal from an automated storage and distribution device, a pharmacist reviews all prescription or medication orders unless a physician, physician’s assistant, or ARNP controls the ordering, preparation, and administration of the medication; or in urgent situations when the resulting delay would harm the patient, including situations in which the patient experiences a sudden change in clinical status (for example, new onset of nausea).

2) Each facility must determine what they will accept as “urgent situations” and which drugs can then be obtained by a nurse, without a pharmacist review.

i) The reason for this “over-ride” must be documented in the patient’s medical record.

ii) Over-rides must be minimized.

 E) Medications are prepared safely

 1) When an on-site, licensed pharmacy is available, only the pharmacy compounds or admixes all sterile medication, intravenous admixtures, or other drugs except in emergencies or when not feasible (when the products stability is short)

2) When mixed on a nursing unit, the nursing unit must maintain a clean, uncluttered, and functionally separate area for product preparation

 F) Medications are safely and accurately administered

 1) The patient is positively identified using two identifiers (excludes use of patient’s room number)

2) The prescriber is notified in the event of an adverse drug reaction or medication error

3) Documentation that medications are administered at proper time, proper dose

4) That the patient is advised of any significant adverse drug reactions

 G) The effects of medication on patients are monitored

 1) Each patient’s response to his or her medication is monitored according to the individual needs of that patient which includes the patient’s response to the medication

2) One must gather the patient’s own perception about side effects, referring to information from the patient’s medical record, laboratory results, and clinical responses to medication

 National Patient Safety Goals that involve the Medication Use System:

 A) Goal:  Improve the safety of using medications.

 1) Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.

2) Standardize and limit the number of drug concentrations available in the organization.

3) Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.

 B)  Goal:  Accurately and completely reconcile medications across the continuum of care.

 1) For full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient.  This process includes a comparison of the medications the organization provides to those on the list.

 2) A complete list of the patient’s medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.

 C) Goal: Improve the effectiveness of communication among caregivers.

 1) For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.

2) Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. (See Shands Core policy 2.53 for a list of banned abbreviations.)

 Finally, it is important before administering any medication, to verify the 5 Rights:

1.) Right Patient,  2.) Right Medication, 3.) Right Dose,  4.) Right Time, and 5.) Right Route

Congratulations Teams!