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Frequent problems with medication systems noted during ISMP hospital evaluations

From the June 3, 1998 issue

ISMP is often asked to assist health care organizations by performing a systems analysis of the medication administration process. So often we see evidence of enthusiastic and creative efforts that effectively prevent many errors. Nevertheless, we also see weaknesses in medication systems that are common to many institutions. Some examples of the most frequently occurring problems and our recommendations for improvement are listed below.

Patient Information: Critical patient information (diagnoses, lab values, allergies, etc.) is often unavailable to pharmacy and nursing staff prior to dispensing or administering drugs for new admissions. More than 25% of prescribing errors alone are directly associated with inadequate patient information, most notably renal and hepatic function, allergies and pregnancy status.1 When drugs are dispensed or administered without adequate patient information, a critical system of double checks is bypassed. Thus, errors in prescribing may not be detected. Health care professionals must identify effective ways to obtain and communicate pertinent clinical information and never rely on admission office staff or unit clerks to supply this data. Do not dispense any drugs unless specific clinical information is included in order screening (see amrinone-amiodarone warning on page 1).

Drug Information: Pharmacists often are not readily available face-to-face on patient care units. Because errors occur most often during the prescribing and administration stages, accessible drug information must always be readily available and close at hand for all staff who prescribe and administer drugs. In addition to computerized drug information, an effective way to accomplish this is by moving the pharmacist, an expert on drugs, into patient care areas. In this way, pharmacists can establish close working relationships with patients and staff, follow the patient's clinical course, and regularly consult with staff about drug selection, dosing and administration. A growing body of research shows that when such moves are made, patient outcomes are improved and both errors and drug costs are significantly reduced while improving patient outcomes.2 Begin by having pharmacy personnel make daily rounds on units or by entering orders directly at terminals on patient care units. Then, progress to a stronger clinical presence in high priority areas, such as ICU, pediatrics, oncology units, OR and ER.

Communication of Drug Information: Policies for handling medication use conflicts between practitioners are often ineffective or absent. Flawed communication, often precipitated by intimidation, contributes to about 10% of the serious errors that occur during drug administration.1 In fact, ISMP receives many reports of lethal errors in which orders were questioned but not changed. Institutions should develop a process that clearly specifies the steps practitioners should take to resolve drug therapy conflicts. All staff should feel the process is workable and effective. Establish maximum doses for high alert drugs so that orders which exceed these doses automatically trigger the policy.

Labeling, Packaging and Drug Nomenclature: Although most drugs are dispensed through a unit dose system, drug administration procedures do not assure that medications remain labeled until they reach the patient's bedside. Often, staff members prepare drugs at a central location by removing pharmacy or manufacturer drug packaging and labeling, and placing the open medications in cups for administration. Thus, the chance for errors, including most often the administration of a drug to the wrong patient, is greatly increased. Institutions should therefore require labeling throughout the drug use process, up to the actual point of administration. Focus groups of pertinent staff members should be used to explore and remedy any obstacles to following these policies, or they will not become practice.

Drug Storage, Stocking and Standardization: Lack of safety procedures for use of automated dispensing technology often contributes to problems. Inadequate check systems may result in drug storage errors. Further, product safety may not be considered when determining which items will be stocked and their location. Also, the usual pharmacist-nurse check systems are often bypassed, especially with first doses. Thus, specific procedures are needed to ensure that items are properly stored. Problematic and dangerous drugs should be dispensed only from the pharmacy. In addition, medications should not be routinely available for administration to patients without appropriate order screening by pharmacists.

Additional examples and references will appear in our next issue.

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