Medication Errors Who Owns Them - Crozer-Keystone Health System - PA

Medication Errors - Who Owns Them?

January 2011 

Patient Safety is everyone's responsibility. Everyone is talking about medication errors - The Joint Commission, Patient Safety Authority, Department of Health, healthcare providers, patients, and the public.

Errors can be the result of orders not being written properly (legibly or appropriately) or acted upon as written. Orders for treatment are the most basic communication tool among healthcare providers. However, when there is a breach in this communication, treatment can be delayed, omitted, or inappropriately provided, resulting in potential injury to the patient. Injury can take the form of a serious physical problem, including death, emotional trauma, and/or loss of trust.  

Additionally, a large source of medication errors is a lack of patient-focused medication management. “Patient focused” includes a clear understanding of the patient’s needs in order to select the appropriate drug, understanding of a patient’s ability to comply with the medication regimen, and medication reconciliation.  

With regard to medication orders, the first golden rule is that orders should be dated, timed, and signed - at all times. Common sources of medication errors often involve the lack of the following:

  • Drug information
  • Patient information
  • Communication

Understanding new drugs - the name, purpose, and side effects, including interactions with other medications is critical in prescribing appropriate medications. Equally important is being sensitive to drugs that "look alike" or "sound alike".  

Ensure key patient information is accurate and available, i.e., patient age, weight, clinical status, use of other medications, vitamins, supplements, and patient allergies.  

Written orders should be clear and legible. Many medication errors are made as a result of an order being illegible and the individual acting on the order not clarifying with the author of the note. Ambiguous abbreviations or abbreviations not on the approved list can also lead to medication errors. The most serious type of error can occur from the use of unnecessary zeros and decimal points. These are not always visualized or when faxed/Xeroxed and can go undetected.

Safe practices are not one person's responsibility; they involve a team effort. All medication errors and all "near misses" need to be reported on an Event Report and processed. This is the only way to properly evaluate and assess where the weaknesses are within the organization so proper corrective action can be taken. Communication among healthcare professionals as well as with patients serves everyone.

Mediciation Errors - Who Owns Them? Questions January 2011

Medication Errors - Who Owns Them? Answers January 2011

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