From Medscape Nurses
Medication Error Prevention for Healthcare Providers
Faculty and Disclosures

CE Information
There are between 44,000 and 98,000 individuals who die every year in hospitals due to preventable medical errors.[1] It has also been reported that this is only part of the problem, as thousands of other patients are adversely affected by medical errors or barely avoid injuries that are nonfatal.[2] These medical errors not only cost the loss of lives, but carry a financial burden that is estimated to be in a range of $17 billion to $29 billion annually. Additionally, there is physical and psychological pain and suffering related to these errors.[1] Another consequence is that medical errors diminish trust and satisfaction in the healthcare system and in healthcare professionals.[1]
Ginette A. Pepper, PhD, RN, FAAN, a Professor and Helen Lowe Bamberger Colby Presidential Endowed Chair and Associate Dean for Research, University of Utah College of Nursing, Salt Lake City, spoke on medication safety for the geriatric nurse practitioner (GNP).[3] Dr. Pepper was trained as a pharmacologist with a nursing focus. She was one of the first NPs to add "geriatric" to her title as well as one of the first NPs to have prescriptive authority.
Safety Principles and the Medication Use Process
Dr. Pepper noted that safety issues are of the utmost importance for all healthcare providers.[3] Nursing as a profession has a long history of regarding patient safety as a primary precept of the profession. Florence Nightingale stated in her book entitled Notes on Hospitals, published in 1859, "the very first requirement in a hospital that it should do the sick no harm."[4]
Nursing schools have long taught that there are "5 Rights" to safe medication delivery to patients. These include the following: right drug; right patient; right dose; right route; and the right time. Dr. Pepper [3] noted that there are several things wrong in teaching medication error prevention this way. The 5 rights are goals, not procedures. They do not recognize the complexity of the nursing role, and they focus on the individual rather than system factors. Further, there is lack of evidence-based best practices on this teaching. Dr. Pepper offered an analogy of the 5 rights for medication as the equivalent of giving airplane pilots the following instructions to avoid crashes: have the right plane; the right passenger; the right airport of origination; the right destination; and the right time.[3]
Cognitive psychologists report that the human brain is creative and is wired to make errors. Dr. Pepper pointed out that if nurses and others in healthcare institutions would start with this assumption, it would be clear that the way to approach error prevention is a systems approach. This method would avoid the "blame game," in which, typically, the last person in the chain of caregivers gets the blame. Usually, this is the nurse who is administering the medications, even though other caregivers may have had a role in the error.
Nurses have 2 roles in medication error prevention: (1) they must check to see that other healthcare providers have not made any errors in any part of the medication order chain; and (2) they must ensure that they themselves do not make an error.[3]
Medication Use Process
There are several nodes or parts of the medication use process where errors can occur. These include prescribing, documenting, transcribing, dispensing, administering, and monitoring.[3] Ordering or prescribing the wrong drug, dosage, or route contributes to 48% of medication errors. Nurses intercept 48% of these types of ordering errors. Transcription errors account for 11% of all errors, of which 23% are intercepted by nurses. Dispensing errors comprise 14% of all medication errors; however, nurses intercept 37% of them. Overall, nurses intercept 58% of all medication errors. Administration errors account for 28% of all errors, but once the medicine has been given, there is no way to intercept it.[5]
Systems-Based Approach vs a Person-Based Approach to Errors
There are 2 basic ways of viewing human error. The first is a "person approach," which has been traditionally used in analysis of medication errors. The person approach looks at medication errors as occurring due to human frailty, including forgetfulness, poor motivation, carelessness, not paying attention, or even negligence. Solutions to errors when viewed from this perspective include disciplinary actions, blame and shame, and even threats of lawsuits.[6]
Alternatively, a systems-based approach expects that errors will occur. Errors are viewed as the end result and not the cause. There is potential for error and recurring errors in every system, and even the best systems fail. Solutions are based on the belief that conditions can be changed, rather than focusing on changing humans. Barriers and safeguards should be implemented to help prevent errors. It is essential to focus on how and why the system failed and not on which individual failed.[6]
It is important to note that many times, some of the best people make the worst mistakes. Errors fall into recurring patterns with the same set of events, no matter which individuals are involved. Approximately 90% of all errors are actually blameless.[6]
The Swiss Cheese Model of Systems Errors
Defenses and barriers are the best ways to prevent errors in a systems-based approach. Each barrier could be viewed as a slice of cheese. In an ideal word, there would be no holes in the barriers. However, in the real world, the various defenses line up like slices of Swiss cheese. When the holes line up, there is a system failure or an error.[6]
The holes emerge due to either active or latent failures in the system, but usually it is a combination of both. Active errors are unsafe acts committed by those on the front lines. In healthcare, this includes nurse practitioners, physicians, nurses, and pharmacists.[6]
Latent errors focus on the conditions surrounding the error. There may have been flaws in the systems that were longstanding. These holes may become apparent when there are local triggering factors based on active errors. In healthcare, types of latent errors include management decisions and organizational processes. Latent failures may be identified and prevented before an error occurs.[6]
Strategies to Help Prevent Errors
According to Dr. Pepper, there are several individual strategies that can be used to help prevent medication errors.[3] Always double check "high-alert drugs" by doing independent calculations. High-alert drugs are those medications that have an increased risk of causing harm to patients when used in error. A list of these drugs has been put together by the Institute of Safe Medication Practices.[7] Another helpful strategy is to take time out between rechecking calculations. Healthcare professionals are more likely to find their own errors when there is time between rechecks. Dr. Pepper stated that even with the practice of double checking medications with another nurse, as is often done with IV drugs, there is a great chance for error. Individuals see what they expect to see. So whatever medication or patient name one nurse may read, the second nurse has a tendency to see as well. A better way to implement double checks would be to have one nurse read what is on the medication package or dose and have the other nurse check it against the order, and then reverse the process.[3]
There are some specific abbreviations that have been frequently mistaken and caused medical errors. These symbols or abbreviations should never be used in any form of communication, including writing prescriptive orders. An example would be writing "qd" for a daily order that can be misinterpreted for "qid," which would quadruple the dose. Another error-prone abbreviation would be to use "U" for a unit. U has sometimes been misinterpreted as a zero, causing an overdose of 10 times the amount of medication that was intended for a patient. The bottom line is that healthcare professionals should write out the words rather than using commonly misread symbols or abbreviations.[8]
Healthcare professionals should put safety ahead of timeliness. Clinicians should exercise caution when out of the normal safety zone of practice. And if an error should occur, the healthcare professional should take the time to report it. If an error happened in one situation for a patient, it is likely that it could happen again in similar circumstances.[3]
Top Reasons for Prescription Errors
Dr. Pepper listed the top reasons for medication errors that nurse practitioners should be aware of when writing prescriptions, especially for older adults.[3] First, illegible or poor handwriting is a cause of error when writing orders. Use of dangerous abbreviations, such as those on the ISMP list, should be avoided.[8] Drug selection is important. Nurse practitioners should avoid ordering drugs listed on the Beers Criteria for patients aged 65 years and older.[9] (The Beers Criteria was developed in 1997 and updated in 2002. It lists drugs with the most potential for causing adverse reactions for older adults.) Another table developed for the updated Beers Criteria includes lists of drugs to avoid when older adults have certain diseases or conditions.[9]
Another key reason for prescription error is using a "trailing zero" after a decimal point when writing a dosage. This can lead to a 10-fold medication error. For example, writing a medication dosage as 1.0 mg may be misinterpreted as 10 mg, if the decimal point is not seen. However, a zero should always precede a decimal point. For example, a medication written as .1 mg could be misinterpreted as 1 mg if the decimal point is missed, leading to a patient receiving 10 times the amount of medicine needed. In this case, the zero should precede the decimal point, as in 0.1 mg. The rule of thumb is that a zero should precede a decimal point but not follow one when writing prescriptions. A way to remember this rule is "Always lead, never follow."[3]
Other common reasons for medication errors include not considering renal dosing and not adjusting for decreased liver blood flow. The patient should be included in any medical decision and informed of what is being ordered. Two final sources of medication errors include not writing the purpose of the medication on the prescription and inadequate contact information for the pharmacist to follow up with the prescriber. An example of a potential error that could be caused by not writing the purpose of the medication on the prescription and not writing adequate contact information on the order would be ordering calcium for a patient with osteoporosis vs a patient with Addison's disease. The dose may be changed to the lower dose if there is no way to consult or to verify the reason with the prescriber.[3]

References
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References
1. Institute of Medicine. To err is human: building a safer health system. Available at: http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf. Accessed November 16, 2006. 2. Committee on Identifying and Preventing Medication Errors; Aspden P, Wolcott J, Bootman L, Cronenwett L, eds. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, Institute of Medicine; 2001. 3. Pepper G. Do no harm: medication safety for the GNP. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 25th Annual Conference; September 27-October 1, 2006; Jacksonville, Florida. 4. Maindonald M, Richardson AM. This passionate study: a dialogue with Florence Nightingale. J Stat Educ. 2004;12:1-11. 5. Bates D, Cullen D, Cooper J, et al. Systems analysis of adverse drug events. JAMA. 1995;274:1599-1603. Abstract 6. Reason R. Human error: models and management. Br Med J. 2000;320:768-770. 7. ISMP's list of high alert medications. Available at: http://www.ismp.org/Tools/highalertmedications.pdf. Accessed November 16, 2006. 8. ISPM's list of error-prone abbreviations, symbols, and dose designations. Available at: http://www.ismp.org/Tools/errorproneabbreviations.pdf. Accessed November 16, 2006. 9. Fick D, Cooper J, Wade W, Waller J, Maclean J, Beers M. Updating the Beers Criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003;163:2716-2724. Abstract
NCGNP 2006: Highlights of the National Conference of Gerontological Nurse Practitioners 25th Annual Meeting 1. Health Disparities Affecting Minority Elderly Populations 2. Medication Error Prevention for Healthcare Providers 3. Research in Action: NPs Make a Difference 4. Ethics and Medical Futility: The Healthcare Professional's Role 5. Strategies to Reduce Medication Errors 6. Individual pharmacists also can use a variety of strategies to reduce medication errors during their daily practice. Some high-risk areas have been identified by ISMP, the FDA, and other agencies. These high-risk areas provide the pharmacist with opportunities to reduce medication errors. Strategies that pharmacists can use to reduce medication errors include: 7. 1. Increase awareness of at-risk populations.
Case: Mr. Jones, a long-time patient at Smiling Face Pharmacy, presents to the pharmacy counter asking for a refill on his furosemide prescription. The pharmacist notices in the computer that Mr. Jones received a 30-day supply of this medication 2 weeks earlier. When the pharmacist comments on this, Mr. Jones insists that he took his last tablet this morning. Mr. Jones then adds that he always takes this medication 3 times a day, because he knows how important it is to control his arthritis pain. The pharmacist realizes that Mr. Jones has confused the furosemide with one of his other medications. 8. Two groups of patients are at increased risk of adverse effects due to medication errors: pediatric and geriatric patients. For both groups, this risk is due to altered pharmacokinetic parameters and lack of published information regarding the use of medications in these groups. For pediatric patients, the risk also is due to the need for calculation of doses based on age and weight and the lack of available dosage forms and concentrations for smaller children. Due to this increased risk of adverse effects, medication errors may do the most harm in these groups. 9. Unfortunately, according to USP reports,5 more than one third of medication errors reaching the patient involved a patient aged 65 years or older. Omission errors, improper dose or quantity errors, and unauthorized medication errors were the most common types among seniors. 10. More than 55% of fatal hospital medication errors involved seniors. Of errors involving seniors, 9.6% of medication errors were classified as harmful. The most harmful medication errors to seniors were wrong route, including tube-feeding liquids given intravenously, and wrong administration technique, including administration of undiluted concentrated medications. 11. To reduce errors, some pharmacists have established double-check systems for calculating doses for these patient groups. A variety of reference books are available to assist with pediatric dosing. Computer alerts can be programmed to remind pharmacists of the recommended weight-based dose for a specific medication. Some computer programs will even calculate the dose based on the patient's age and weight. Keeping the age and weight of pediatric patients up-to-date can prevent underdosing of medications. 12. For geriatric patients, decreased renal function can reduce the elimination of medications from the body, leading to drug accumulation in the body. Adjusting medications for renal function can reduce this risk. The pharmacist also can consider the patient's ability to adhere to the recommended therapy. Some geriatric patients may have difficulty remembering to take a medication, leading them to miss doses or take extra doses. If a patient is taking multiple medications, he or she may become confused about the indication or directions. Dosing reminders and pill boxes are available to reduce this problem. 13. 2. Avoid abbreviations and nomenclature.
The use of abbreviations, symbols, and dose designations is common in writing prescriptions. Although the use of this shorthand may prove time-saving for the writer, it has been criticized as a significant cause of confusion or misinterpretation. Such abbreviations may include abbreviated medication names, such as MTX (methotrexate), or dosing abbreviations, such as QD (once a day). Due to confusion caused by abbreviations, ISMP has developed a list of abbreviations that should be avoided (Table 2).8 The Joint Commission also requires accredited health care facilities to develop and publish a list of approved abbreviations, in conjunction with a list of "do not use" abbreviations, acronyms, and symbols. 14. Along with avoiding abbreviations, the pharmacist should avoid confusing dose designations. When writing whole numbers or medication strengths or dosages, avoid adding a decimal point with a trailing zero. For example, write "55 mg," rather than "55.0 mg." If the decimal point is not noticed, the administered dose could be 10-fold higher than intended. 15. A similar concern exists when writing a decimal fraction for a number less than 1. Such numbers should always have a zero preceding the decimal point. For example, write "0.55 mg," rather than ".55 mg." If the decimal point is not seen, the administered dose could be 100-fold higher than intended. 16. 3. Recognize prescription look-alike/sound-alike medications.
Case: After taking a prescription over the phone, the pharmacy intern hands the prescription to the technician, asking her to process the prescription as soon as possible, because the patient is on his way from the physician's office. When the technician attempts to enter the information into the computer, she comments to the intern that she does not know how she is going to get the correct dose. The intern informs her that Lamictal is available as a 200-mg tablet, so the patient would take 1 tablet per dose. The surprised technician comments that she thought the prescription was for Lamisil, and that was why she did not know how to provide a 200-mg dose. Table 3 | | 17. Although the FDA is working to prevent and eliminate look-alike/sound-alike medication names, medication errors still occur due to look-alike/sound-alike names. The ISMP has developed an extensive list of confused drug names. This list contains more than 300 medication pairs that have been involved in medication errors published in the ISMP Medication Safety Alert! Although the entire list is available at www.ismp.org, Table 39 includes a partial list. A similar list is maintained by the National Association of Chain Drug Stores on its Web site, www.nacds.org. This list is a more modest list of medications encountered in ambulatory pharmacy settings. 18. For health care facilities, the Joint Commission also has developed a list of look-alike/sound-alike medication names. This list is available at www.jointcommission.org. From this list, the Joint Commission requires each accredited organization to identify a list of lookalike/ sound-alike medications in order to meet the safety requirements of the National Patient Safety Goals within the organization. 19. Not only do medication names look or sound alike, but different packaging also can look alike. Sadly, this was the case for the infants who received the concentrated heparin as catheter flushes. The pharmacist should avoid using color as a means to recognize a product. For commonly confused or high-risk medications, the pharmacist can ask another person to double-check the product. 20. 4. Beware of OTC family extensions and standardized labeling.
Case: As soon as the pharmacy opens in the morning, a woman approaches the pharmacy counter with a box of Alka- Seltzer PM and Claritin. She comments that she is going to race home to take these medications. She also comments that she always uses Claritin for her allergies, because she cannot afford to fall asleep at work. When the pharmacist informs the woman that Alka-Seltzer PM has a sedating antihistamine as one of its active ingredients, the woman insists that Alka-Seltzer is "just for my heartburn." The pharmacist sends the technician into the aisle to grab a box of the original Alka-Seltzer for the woman, while she explains to the patient that many different Alka-Seltzer products exist. 21. Manufacturers of OTC products have learned to take advantage of recognizable trade names. They have developed families of products with differing active ingredients but similar product names. These medications are approved for indications as varied as arthritis, allergy/sinus, cough/cold, and sleeplessness, not to mention the numerous formulations for pediatric patients. Simply looking at the trade name can confuse patients and pharmacists as to the actual ingredients. 22. In an effort to help patients use OTC medications safely, the FDA passed regulations requiring a standardized "Drug Facts" label on OTC medications. This label is modeled after the Nutrition Facts label found on foods. The label is intended to clearly list active ingredients, uses, warnings, dosage, directions, and other information. When discussing OTC medications with patients, the pharmacist should refer to the label for active ingredient lists. The pharmacist also can educate the patient on what information is contained on the label. 23. 5. Focus on high-alert medications.
High-alert medications are medicines that bear a heightened risk of causing significant patient harm if used incorrectly. These medications may or may not be associated with an increased incidence of medication errors, but all of them are associated with significant consequences if an error occurred. Table 4 | | 24. ISMP creates and frequently updates a list of potential high-alert medications. This list is created using data from the USP and ISMP database on medication errors, input from practitioners on medications that were most frequently considered high-alert drugs by individuals and organizations, and input from the ISMP clinical staff, advisory board, and safety experts. The list is divided into classes of medications (Table 4) and specific medications (Table 5) associated with significant consequences if an error occurred.10 Of particular concern are medications with multiple formulations. 25. The availability of this list allows pharmacies and health care organizations to develop strategies to prevent errors with these medications. Pharmacists may consider limiting access to these medications within the pharmacy and offering training on safeguards to prevent errors to personnel who would have access to them. When processing orders, the pharmacist should pay attention to automated alerts in the computer related to these medications. The development of standardized orders for these medications also can reduce the risk of errors. When storing the product, the use of auxiliary labels on the original package also can serve as an alert to pharmacy staff as to the high-alert nature of the medication. 26. 6. Look for duplicate therapies and interactions.
Case: Mrs. Smith is admitted to the local hospital with a gastrointestinal bleed. Upon admission, the pharmacist asks Mrs. Smith's family if they can provide her with a list of all the medications that she was taking. Mr. Smith pulls a slip of paper from his wife's wallet, on which is written: Coumadin 2 mg daily, Toprol XL 50 mg twice daily, furosemide 20 mg daily, and metoprolol 50 mg twice daily. When the pharmacist asks if Mrs. Smith takes any OTC medications, her husband admits that she does take Motrin and Advil a "few times a day" to help with pain. He also pulls out a packet of Goody's powder from his wife's purse and says that he sees her use this product numerous times a day as well. 27. Drug interactions and duplicate therapies can increase the risk of adverse events. Drug interactions may alter the metabolism or excretion of one or both medications. This may cause reduced effectiveness or toxic accumulation. Obtaining a complete list of prescription, OTC, and herbal products from the patient can reduce this risk. Many pharmacy computer systems are able to detect drug interactions if this information is provided. Table 5 | | 28. Duplicate therapies can increase the risk of adverse effects. Products with multiple formulations, such as immediate-release and sustained-release, can prove confusing to patients. Patients also may not understand that 2 medications contain different ingredients but are in the same drug class, such as morphine and meperidine. Another confusing situation for patients occurs when products containing more than one active ingredient are prescribed, such as Vicodin or various cough syrups. If a patient is unsure if one medication was intended to replace another, this should be clarified before dispensing the new prescription. 29. 7. Do not take shortcuts around technology safeguards.
Case: On an extremely busy Monday, the prescriptions begin to pile up. An irate patient screams at the technician that she has been waiting for 15 minutes for the prescription for her sick child. The technician, upon noting where the prescription is in the filling process, comments to the pharmacist that she needs the computer alerts verified for the prescription before she can submit it for electronic adjudication. As the pharmacist races to answer a phone call, she instructs the technician to enter her initials into the computer alerts to bypass them. 30. Safeguards established in the pharmacy were developed to prevent medication errors or in response to them. Although the pharmacist may view these safeguards as time-intensive, they exist for a purpose. Bypassing such systems, including computer alerts and bar coding, increases the risk of medication errors. 31. 8. Report errors to improve process.
Case: The pharmacist speaks with a patient who has returned to the pharmacy with a prescription bottle containing the wrong medication. The patient has not taken any of the medication and simply wants the pharmacist to correct the error. When the patient leaves, the pharmacist throws the evidence of the error into the trash. The technician gently reminds him that they have a new documentation process for evaluating the cause of an error-to which the pharmacist comments, "I do not want to get in trouble for this, so I am not going to report it. Besides, the patient did not even take the medication." 32. Reporting medication errors plays an important role in preventing further errors. The intent behind reporting errors is not to point blame at anyone. It is to identify system failures that can be altered to prevent future errors. 33. The reporting can be completed in several ways. The USP operates 3 medication error�reporting systems, including the Medication Errors Reporting (MER) Program, the Veterinary Practitioners' Reporting Program, and MEDMARX. The MER Program, operated in conjunction with ISMP, allows the health care professional to report medication errors online, by phone (1-800-23-ERROR), or by mailing or faxing the report to USP. The anonymous information is reviewed by USP staff, then forwarded to the FDA and manufacturers. All USP programs can be accessed through its Web site. 34. When an error has occurred, the patient or caregivers should be notified. Ideally, the patient should be informed within 24 hours after the event is discovered. Disclosing the error will preserve the patient's autonomy and patient� pharmacist trust. The pharmacist should acknowledge that the event occurred and provide the patient with available facts about the incident. 35. It is appropriate to apologize, take responsibility, and show commitment to finding out why the error occurred. The patient should be informed of the impact that the event will have on the patient now or in the future, along with steps being taken to mitigate the effects of the injury. The patient will also appreciate learning the steps being taken to prevent a recurrence. Table 6 | | 36. 9. Control the environment.
Pharmacies can be high-stress settings. In the MEDMARX database, health care facilities often attributed medication errors to workplace distractions, staffing issues such as shift changes and floating staff, and workload increases. Despite the stress, pharmacists are trained to expect perfection. 37. Although not all environmental factors within the pharmacy can be controlled, some stress factors can be controlled. The pharmacy should have adequate lighting. The work space should remain uncluttered. Answering phones quickly can reduce the noise. If staffing does not allow for these changes to occur, increased staffing may be necessary. 38. The pharmacist should strive to reduce interruptions. Interruptions during a phone call can cause the pharmacist to miss vital information pertaining to a patient or prescription. If the pharmacist is interrupted while verifying a prescription, the verification process should be started again, rather than guessing at what stage to resume. 39. 10. Educate the patient.
Patients can play a vital role in preventing and detecting medication errors. Patients also should consider the "5 Rights" for medication safety. The pharmacist can educate patients to consider the 5 rights before taking any medication, along with providing tips on ways to reduce the risk of missing one of the rights (Table 6). 40. Summary 41. Medication errors are receiving national attention among health care professionals and patients. Despite national and local strategies to reduce errors, the incidence remains frighteningly high. The cases presented throughout this article demonstrate that medication errors can occur at any point in the prescription process and are varied in nature. Numerous strategies can be undertaken by the pharmacist to reduce errors in the pharmacy. ISMP provides lists of look-alike/sound-alike medications, high-risk medications, and recommendations for abbreviations, which are a good starting point for developing strategies within the pharmacy for preventing errors.