2.5 Preventing Medication Errors
Preventing medication errors has been a key target for improving safety since the 1990s. Despite error reduction strategies, implementing new technologies, and streamlining processes, medication errors remain a significant concern with error rates of 8%-25% during medication administration.[1] Furthermore, a substantial proportion of errors occur in hospitalized children due to the complexity of weight-based pediatric dosing.[2]
Several prevention initiatives have been developed to ensure safe medication administration such as the following strategies[3]:
- Routinely checking the rights of medication administration
- Standardizing communication such as “tall man lettering,” alerts to “look alike-sound alike” drug names, avoidance of abbreviations, and standards for expressing numerical dosages
- Focusing on high-alert medications that have a higher likelihood of resulting in patient harm if involved in an administration error, such as anticoagulants, insulins, opioids, and chemotherapy agents
- Standardizing labelling of medication using visual cues as safeguards
- Optimizing nursing workflow to minimize errors, such as minimizing interruptions and double checking high alert medications
- Implementing technology like barcode medication administration and smart infusion pumps
Read the article “Medication Administration Errors” on the Agency of Healthcare Research and Quality (AHRQ) website.[4]
The Joint Commission’s National Patient Safety Goals related to mediation administration were previously discussed in the “Legal Foundations and National Guidelines for Safe Medication Administration” section of this chapter. This section will further discuss additional safety initiatives established by the Institute of Medicine (IOM), World Health Organization (WHO), Institute for Safe Medication Practices (ISMP), and Quality and Safe Education for Nurses (QSEN) to prevent medication errors.
Institute of Medicine
To Err is Human: Building a Safer Health System Report
The national focus on reducing medical errors has been in place since the 1990s. The Institute of Medicine (IOM) released a historic report in 1999 titled To Err is Human: Building a Safer Health System. The report stated that errors caused between 44,000 and 98,000 deaths every year in American hospitals and over one million injuries. The IOM report called for a 50% reduction in medical errors over five years. Its goal was to break the cycle of inaction regarding medical errors by advocating for a comprehensive approach to improving patient safety. The IOM 1999 report changed the focus of patient safety from dispensing blame to improving systems.[5]
Preventing Medication Errors Report
In 2007 the IOM published a follow-up report titled Preventing Medication Errors, reporting that more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized client experiences at least one medication error each day. This report emphas