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Selecting the best error-prevention "tools" for the job

From the February 2006 issue

Last month’s article Drug name confusion: Let’s resolve to do better, highlighted the fact that, despite error-prevention efforts, look-alike drug names, sound-alike drug names, and look-alike packaging continue to be a common source of medication errors. Selecting the best error-prevention strategies is not an easy task. Even when system-based causes such as look- and sound-alike issues have been identified, it may be unclear which error-prevention strategies will be most effective.

Listed below and in Table 1 are examples of error-prevention strategies in order of effectiveness for creating lasting system changes for safe medication use. Those listed first are more powerful because they focus on changes to the system in which individuals operate. As the list descends, strategies that target system changes, but rely in some part on human vigilance and memory are presented. Strategies toward the end are familiar and often easy to implement, but rely entirely on human vigilance.

Fail-safes and constraints are among the most powerful and effective error-prevention strategies. They involve true system changes in the design of products or how individuals interact within the system. Examples outside of healthcare would include the inability to start a car while the gearshift is in reverse or using fingerprint verification to enter a building or computer system. At a community pharmacy where the pharmacy computer system is integrated with the cash register, a fail-safe would prevent the clerk from “ringing up” the prescription unless final verification by a pharmacist was noted in the system.

Forcing functions are procedures that create a “hard stop” during a process to help ensure that important information is provided before proceeding; often referred to as a “lock and key” design. For example, an electronic prescribing system in a physician’s office that requires the indication to be entered for each medication before it is processed and sent to the pharmacy; a pharmacy computer system that prevents overriding selected high-alert messages without a notation (e.g., entry of the patientspecific indication for selected error-prone medications); or a bar-code scanning system that does not allow final verification of a product without a positive match between the selected product and the profiled medication.

Automation and computerization of medication-use processes and tasks can lessen human fallibility by limiting reliance on memory. Examples include use of electronic prescribing software that includes clinical decision support; pharmacy computer systems that can receive prescriptions sent electronically from a prescriber’s hand-held device or computer and thus eliminate transcriptions and misinterpretations; robotic prescription preparation and dispensing technology; and computer systems that provide accurate warnings related to allergies, significant drug interactions, and excessive doses.

Standardization creates a uniform model to adhere to when performing various functions and it tends to reduce the complexity and variation of a specific process. For example, standardized processes could be created to guide the pharmacist’s final verification of a medication or to enhance the safety of giving or receiving a telephoned medication order. Prescriber use of carefully designed preprinted prescription blanks that contain commonly used protocols (e.g., steroid tapers, insulin regimens, preprocedure instructions) or frequently prescribed medications can reduce problems with confusing or missing instructions and illegible handwriting. On its own, standardization relies on human vigilance to ensure that a process is followed; therefore, it is less effective than the strategies mentioned previously.

Redundancies incorporate duplicate steps or add another individual to a process to force additional checks in the system. Involving two individuals in a process reduces the likelihood that both will make the same error with the same medication for the same patient. However, the potential for error still exists since the redundant step may be omitted or ignored. Examples of redundancies include use of both brand and generic names when communicating medication information or requiring independent double-checks of high-alert medications before dispensing. Patient counseling is often an underutilized redundancy that can detect many errors.

Reminders and checklists help make important information readily available. For example, using auxiliary labels to distinguish products; building look- and soundalike alerts into order entry systems; and using preprinted prescription blanks that include prompts for important information (e.g., medication indication, allergies, patient birth date).

Rules and policies are useful and necessary in organizations. Effective rules and policies should guide staff toward an intended positive outcome. However, some may add unnecessary complexity and may be met with resistance, even rightfully so, especially when implemented in response to an error. Because their use relies on memory, they should be used as a foundation to support more effective strategies that target system issues.

Education and informationare important tactics when combined with other strategies that strengthen the medication- use system. The effectiveness of these tactics relies on an individual’s ability to remember what has been presented. Thus, on their own, they offer little leverage to prevent errors.

When implementing error-prevention strategies in your organization, each of these is important to consider. While strategies at the bottom of the list may be used initially, we must realize that they will not be effective for long-lasting error prevention when used alone. In order to do a better job at preventing drug name mix-ups, as well as other types of medication errors, we need to employ a variety of strategies that focus on system issues and address human factors issues for those who work within that system. Since people cannot be expected to compensate for weak systems, routinely evaluate the error-prevention strategies being used in your organization. Consider if there are more powerful strategies that could be implemented to enhance medication safety.


Table 1. Rank order of error-reduction strategies


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