Medication Safety

January 11, 2018 | Ambulatory Care 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. 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 U.S. 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)...

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