Technology for Medication Safety

Medication mishaps are among the most common errors in healthcare; on average a hospital patient is subject to more than one medication error per day, although many of the errors do not result in harm (IOM). Medication errors that cause patient injury are called adverse drug events (ADEs) and are estimated to occur with nearly 5% of hospitalized patients (Hauck and Zhao). About half of all ADEs are preventable (AHRQ PSNet "Medication Errors").

Errors can happen at any stage of medication-use process, although the greatest risk of error is associated with the prescribing and administering of medications. In a seminal systems analysis of ADEs in the medication-use process, researchers found that most medication errors, as well as preventable ADEs, occurred in the prescribing and administration stages (Leape et al.). Although the study was published in 1995, it continues to be widely cited for describing medication errors by stage of the medication-use process. Errors also commonly occur during the monitoring phase, although the study did not evaluate that aspect of the medication-use process.

ECRI recommends that organizations consider a range of strategies to prevent errors using a hierarchy of error-reduction techniques based on the impact that they can have in preventing errors. These include low-impact strategies, such as practitioner education, and moderate-impact strategies, such as standardization and process simplification, to reduce the likelihood of errors. By far, the most effective strategies are the high-impact ones which incorporate fail-safe mechanisms, automation, and forcing functions that provide a barrier or safeguard to prevent an unsafe action from adversely affecting patient safety. ("ECRI Patient Safety Organization")

Well-designed technology has an undisputed role as a high-impact strategy to prevent medication errors in a variety of ways, such as supporting clinical decision-making, improving patient and medication identification, and supporting practitioner workflow. Examples of technologies available during each phase...