Medication Safety

November 6, 2017 | Healthcare Risk, Quality, & Safety Guidance

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Medication errors are the most common adverse events in healthcare, and as a result, medication safety has become a top priority for healthcare organizations. Nearly every patient treated in an acute care setting receives at least one medication. The medication management process is complex, encompassing several phases, including prescribing, dispensing, administering, and monitoring. The sheer number of drugs administered in healthcare facilities increases the likelihood that adverse medication events will occur if prevention systems are not in place.

For example, a month-long study of nearly 1,500 patients on an antibiotic regimen found that one in five patients experienced an adverse medication event. Further, the study found that nearly one-fifth of the regimens administered were not clinically indicated. (Tamma et al.)

Overall, 1 in 20 patients is likely to experience a medication-related event (AHRQ), and adverse drug events factor into nearly 2 million hospital stays annually (Office of Disease Prevention and Health Promotion). The US Food and Drug Administration (U.S. FDA) received nearly 1.2 million reports of adverse drug events in both 2015 and 2016.

Medication safety is an ongoing goal for risk managers, pharmacists, physicians, nurses, and other care providers. Because medication events can involve many individuals, processes, and systems, risk managers need to help their organizations adopt a multidisciplinary approach to medication safety.

Many medication-event prevention strategies are inexpensive, common sense initiatives, such as separating look-alike drugs and capitalizing different letters in the names of sound-alike drugs (ISMP "FDA and ISMP Lists"). Other approaches, such as computerized provider order-entry (CPOE) systems and bar-coded medication administration (BCMA) systems, will require major operational changes throughout the organization, as well as a financial investment.

While it may seem that a medication administration-related adverse event is the result of an obvious error or problem, further analysis is typically necessary to identify the many underlying circumstances or systems issues that contributed to the event. Unfortunately, with many medication administration events, the tendency is to focus on the individual performance of the nurse who gave the medication and his or her adherence (or perceived...

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