April SafetyFirst Topic is Medication Safety: Through a Pharmacist's Eyes


Quality | Safety | Service

By Janet Fischer, Pharmacist, Sts. Mary & Elizabeth Hospital

In April, KentuckyOne Health is focusing on medication safety as part of the SafetyFirst program. Last week, we learned about the common sources of error and steps for improving medication safety in this article drawn from the American Hospital Association:

This week, Janet Fischer, a pharmacist at Sts. Mary & Elizabeth Hospital, is sharing her learning points and specific safety techniques with employees to offer ways to reduce medication errors and increase patient safety.  

The world of pharmaceuticals is a complex and confusing one. Thousands of medications are administered every day in our facilities and in our own homes, all of which have the potential to cause harm if not used appropriately; or sometimes even if they are. Medications can significantly improve the quality of our lives and even be lifesaving, but they can also have the opposite effect. As health care providers and consumers, we must navigate a sea of look-alike, sound-alike drugs that come in many different strengths/concentrations and different formulations. We all can appreciate the challenges faced in dealing with medications on a daily basis, but because drugs are so ubiquitous in our world, there can also be a tendency for us to become complacent in our approach to handling them. 

Whether you are a physician, nurse, pharmacist, respiratory therapist, or other health professional, you have more than likely been involved in some sort of medication error or at least a near-miss. Each step of the medication use process (prescribing, transcribing, medication reconciliation, storage, preparation and dispensing, administration, monitoring) presents a different opportunity for a mistake to occur. Therefore, each step must be addressed in our efforts to increase medication safety.

Medication safety is not a new buzz word. The topic has been long recognized as an important one, and is given emphasis by regulatory agencies, health care professional associations and consumer interest groups. We should all be familiar with the Medication Management Standards and Patient Safety Goals of The Joint Commission (TJC). The Institute for Safe Medication Practices (ISMP) devotes its entire existence to addressing medication safety concerns through the examination of reported adverse medication events and near misses and the establishment of recommended strategies and best practices to minimize the risks for future errors to occur.

Starting in 2014, ISMP’s Targeted Best Medication Practices include specific recommendations for chemotherapy agents, oral liquids, neuromuscular blocking agents, high-alert medications and antidotes/reversal or rescue agents, as well as other medications. The National Institute of Occupational Safety and Health (NIOSH) alerts and USP 797, 795 and 800 standards address sterile and non-sterile compounding and the preparation and handling of hazardous drugs. The American Society of Health-System Pharmacists offers recommendations regarding the same.

Medication safety awareness should start from the very beginning of the medication use process and continue throughout. Before a drug is even made available on our formularies, the Pharmacy & Therapeutics Committee has the important task of evaluating not only its benefits, but also its safety risks. Before the initial offering of the drug for use, specific safety strategies to reduce identified risks should be established and educated.

Any or all of the following are examples of strategies that may be employed at various points along the medication use pathway for high-alert/high-risk drugs, including those with look-alike/sound-alike names: tall-man lettering, restricted use, policy and procedures, standardized protocols/preprinted order sets/electronic power plans, segregated storage, cautionary labeling/color coding, independent double-checks, smart pump use, monitoring requirements, education and staff competency requirements.

Establishment of safety strategies is only the beginning, however. It is important to remember we must also continually evaluate their effectiveness. Through the analysis of medication errors reports within our own four walls, as well as outside information received, we must look for ways to improve our efforts and outcomes.

Technology can certainly be one of the best ways to address safety concerns and help ensure the right patient gets the right dose of the right drug at the right time by the right route of administration. Electronic prescribing/CPOE reduces problems with handwriting legibility and transcription, and also offers many possibilities for standardization. The electronic medical record gives us immediate access to patient information essentials. It makes it easier for pharmacists to identify therapeutic duplications and drug interactions, as well as easier for clinicians to monitor patient responses. Barcode scanning technology reduces the risk of errors in dispensing and administration, and can improve the accuracy of documentation.

However, not all facilities have the same level of technology available, and in order to be most effective technology must be reliable and must be used the way it is intended every time. Additionally, we must recognize technologies can come with their own set of challenges that have to be addressed: system complexity and/or information overload, user error, alert fatigue, system upkeep, system downtime, lack of system flexibility and a false sense of security by users.  

In our fast-paced environments, we often feel rushed to get to the next thing, but we can never overlook the importance of slowing down, paying attention to detail, and having a questioning attitude whenever we are dealing with medications. As leaders and health care providers, we must embrace medication safety strategies as important safeguards to protect us and our patients, and recognize that shortcuts are never appropriate.

We must recognize and educate our staffs regarding the importance of reporting and discussing near-misses as well as medication errors which reach the patient. As we continue to strive to reach our goal of doing no harm to our patients, the importance of medication safety looms large in creating a highly reliable organization. We must truly value its importance and prioritize keeping medication safety in the forefront of our SafetyFirst efforts.  

Independent Double-Check is a check in which a second person with no prior knowledge of the calculation/task, such as medication retrieval or dose preparation, goes through the required steps and arrives at his/her own answer/conclusion (without knowing the original answer/conclusion). The independent check can be an important safety strategy to help mitigate our human fallibility.  However, the word independent is the key to its value as a Peer Checking technique.  

High-Alert or High-Risk Medications are defined by TJC as drugs involved in a high percentage of errors and/or sentinel events, as well as medications which carry a high risk for abuse or other adverse outcomes. Examples may include investigational drugs, controlled medications, medications with a narrow therapeutic range, psychotherapeutic medications, and look-alike/sound-alike medications. Your facility should have a list of high-alert medications based on its own drug usage and internal data regarding medication errors. Staff should be knowledgeable about the list and the specific safety strategies in place to minimize errors with these drugs. Technique: Self-Checking with STAR; Peer-Checking

Order Clarification is of the utmost importance to medication safety. If any part of a medication order is unclear or raises a concern or question, the order must be clarified with the prescriber prior to the medication being administered to the patient. The pharmacist or nurse should never guess or assume the intent of the prescriber, or feel uncomfortable in expressing a concern regarding medication safety. We must all feel like we can stop the line at any time. Technique: Stop and Resolve/Validate and Verify; SBAR

Medication Reconciliation at the time of admission and discharge is an important step in ongoing medication safety for our patients. Accuracy and attention to detail in the gathering of home medication information is very important as the patient accesses our care. The same accuracy and attention to detail is just as important in providing medication instructions and education to our patients as they leave our care. Technique: Validate and Verify; Self-Checking with STAR

Smart Pump software is designed to reduce dose errors with intravenous medications when standardized medication concentrations and programmed guardrails are used. Guardrails should always be used when available. Wildcard entries should be used only if guardrails for a particular drug are not available in the pump.  

Medication Use Policies and Procedures are valuable tools in providing guidance regarding the safe use of medications generally as well as specifically. It is a good practice to routinely review key policies with staff during department meetings and safety huddles. Emphasis on awareness and education are important to maintaining our focus on medication safety.