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 overlooked.

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.