Medication error prevention "toolbox
From the June 2, 1999 issue
Selecting the best strategy to remedy medication errors is
not easy. Often, the most effective action is not obvious
and the best error prevention tools to use in each situation
are not clear, even when system-based causes have been identified.
Below, we list examples of error prevention tools in order
of their effectiveness for creating lasting changes for safe
medication use. Items at the top of the list, such as computerization
and forcing functions, are examples of more powerful tools
because they fix the system. Next are tools that attempt to
fix the system, yet rely in some part on human vigilance and
memory. Those at the end, such as education and information,
are old, familiar tools that are intended to fix people. While
many rely on these older tools, they are weak and ineffectual
when used alone.
Forcing functions and constraints are the most powerful
and effective error prevention tools. Their use results in
designing processes so that errors are virtually impossible
or difficult to make. Examples include removing potassium
chloride for injection concentrate from all patient care areas;
using medication cups or specially designed oral syringes
(not parenteral syringes) that will not connect to IV tubing
for all liquid oral medications; and eliminating nursing access
to the pharmacy when it is closed by establishing a carefully
selected nighttime formulary and dispensing cabinet.
Automation and computerization of medication use processes
and tasks can lessen human fallibility by limiting reliance
on memory. Examples include use of technologically and clinically
sound computerized drug information systems; direct physician
order entry, which provides drug information and warnings
during order input; and use of IV infusion pumps with fail-safe
design mechanisms to prevent free-flow.
Drug protocols and standard order forms guide the
safe use of medications by eliminating problems with illegible
handwriting and standardizing safe order communication. Yet
they offer less leverage as an error prevention tool than
those above since they rely on human vigilance for implementation.
Nevertheless, there may be times when this is the most appropriate
and only tool available to remedy a medication use problem.
Independent double check systems and other redundancies
are tools that can reduce the risk of error by having one
person independently check another's work. The likelihood
of two individuals making the same error with the same medication
for the same patient is quite small. Yet the potential for
error still exists since this strategy is designed to detect
human error, not prevent it.
Rules and policies: Most people prefer to intervene
in a system at the level of rules and policies. Yet establishing
new rules and enforcing old policies is often reactive and
intended to control people, not necessarily fix the system.
They often add system complexity unnecessarily. While rules
and policies are useful and necessary in organizations, they
should be used primarily to support more effective error prevention
strategies designed to fix the system.
Education and Information: Staff education can be
an important error prevention strategy when combined with
other strategies that strengthen the medication use system.
However, it is a weak link with little leverage to prevent
errors when attempting to use only this strategy for reducing
errors. The ongoing nature of effective education and its
unrealistic dependence on correct human performance is often
While each error prevention tool can play an important role
in error prevention, beware of those that, on the surface,
seem to provide the easiest and fastest solution. Since people
cannot be expected to compensate for weak systems, select
high-leverage error prevention tools that are designed to
fix the system, not just people, whenever possible.