February 10, 2012 | Ambulatory Care Risk, Quality, & Safety Guidance
Adverse drug events and medication errors are the most common types of medical incidents in healthcare. Estimates of the proportion of outpatients who experience at least one adverse drug event per year range from 5% to 35%. For example, one 2009 study found that 7% of adult outpatient visits and about 20% of pediatric outpatient visits were associated with an error involving medications used in the practice or at home. The stage in which errors most often occur is medication administration, followed by medication prescribing. (Walsh et al.)
Not all medication-related adverse events are preventable. For example, a patient who has no history of drug allergies may develop an allergic reaction to an antibiotic; this type of event is considered nonpreventable. If, however, a patient has a documented history of an allergic reaction to a particular medication, a nurse administers that medication to the patient without checking the record or asking the patient whether he or she has any allergies, and the patient suffers an adverse reaction, the event is considered a preventable medication error.
This Guidance Article discusses the following:
When preparing to administer medication to a patient, clinicians must first confirm the seven “rights.” The seven “rights” are not a stand-alone guideline; the organization must give staff members the appropriate tools, strategies, and support. For example, as discussed in later sections of this Guidance Article, providers cannot focus on the seven “rights” if medication orders are unclear, if look-alike/sound-alike medications are stored together, or if high-alert medications are not properly separated, for example. Nevertheless, the clinician must ensure...