In our previous blog Medication Safety – A Priority in Patient Safety, we briefly touched on the three priority areas where medication errors are most likely to happen. These are certain high-risk situations, when patients are using multiple drugs, and during transition of care.
We will be discussing strategies to reduce medication errors in high-risk situations in this blog. In the context of medication safety, high-risk situations relate to those circumstances associated with a significant risk of medication-related harm, such as situations arising from look-alike, sound-alike (LASA) medications and high-alert medications. WHO has grouped high-risk situations into three broad factors:
1. Medication factors
2. Provider and patient factors
3. Systems factors (work environment)
Medication Factors
Medication factors include the use of high-risk (high-alert) medications, often medicines with a low therapeutic index. The development of local high-risk medication lists that are regularly updated help healthcare professionals focus on particular risks in their own workplace. However, merely creating a high-risk medication list without associated risk reduction strategies will not be enough.
Strategies to reduce harm from high-risk (high-alert) medications
Due to the complexity of systems in healthcare, the Institute for Safe Medication Practices (ISMP) has highlighted that a single strategy for addressing the risks associated with each high-risk (high-alert) medication in the acute care setting is rarely sufficient.
The following measures may therefore be considered to ensure medication safety:
- ● Maximize access to provide necessary information on medications when critical tasks are being performed.
- ● Standardize clinically sound, uniform models of care or products to reduce variation and complexity.
- ● Simplify the number of steps in the process of handovers without eliminating crucial redundancies.
- ● Keep antidotes, reversal agents or remedial measures readily available and ensure staff are appropriately trained to manage such errors.
- ● Proactively identify risks and minimize their effects. Built in safeguards to prevent or respond to failures.
- ● Maximize access to provide necessary information on medications when critical tasks are being performed.
Provider and Patient Factors
Provider Factor
Provider factors may be related to the healthcare professional providing patient care or the patient being treated. Poor prescribing practices by healthcare professionals include over-prescribing, under-prescribing and misprescribing. All of these potentially inappropriate prescribing can contribute to an unfavorable risk–benefit ratio, and reduce the benefits of these medications to the patient.
Healthcare professionals are also involved in ensuring safe storage, preparation, dispensing, administration and monitoring of medications. These different steps of the medication use process are no longer the sole responsibility of any single healthcare group. However, it is vital that there is good communication between different groups of healthcare providers.
Resource-limited healthcare settings are often characterized by a lack of electronic support systems for prescribing or dispensing, overcrowding of patients, staff shortages and inadequate monitoring. In such circumstances poor prescribing practices, such as the use of error-prone abbreviations or illegible handwriting increase the risk of medication errors.
Patients Factor
It is well known that adverse drug events occur most often at the extremes of life (in the very young and elder people). In elderly, who are likely to be receiving several medications concomitantly, adding to the risk of adverse drug events. In addition, the harm of some of these medication combinations may sometimes be synergistic and be greater than the sum of the risks of harm of the individual agents.
Polypharmacy was the second major factor predicting risk of experiencing a medication error in adult inpatients and increased risk of harm.
Multi-morbidity is becoming more prevalent as life expectancy increases in many countries around the world. A meta-analysis that included 75 studies from primary care demonstrated that mental-physical multimorbidity was associated with an increased risk of harm.
High-risk medical conditions predispose patients to an increased risk of adverse drug reactions, particularly renal or hepatic dysfunction and cardiac failure (where both kidney and liver can be compromised together).
Strategies to reduce medication errors related to provider and patient factors
There should be a systems approach to counter the effects of human fallibility. This approach concentrates on the conditions under which people work and endeavors to build the defenses required to avert errors or limit their effects.
- ● At the prescribing level: pharmacist/nurse to ensure appropriate medicine, dose, route and duration written for the right patient in the prescription by a certified medical practitioner.
- ● At the storage level: Ensuring medications stored accordingly to the right storage conditions and right labeling. Also, best arrangement practices are often associated with LASA and FIFO principles (LASA – Look Alike, Sound Alike & FIFO – First In First Out).
- ● Standardizing the medication preparation, dispensing and administration following the rights – either 6R, 7R or 10R, whichever applies to the organization’s policy.
- ● Inter-professional educational initiatives may help healthcare professionals to learn to work better together in multidisciplinary teams to promote patient safety.
- ● Principles of co-production of resources and partnership with patients and caregivers should be applied in relation to developing systems.
- ● Core prescribing competencies are relevant to all the prescribing providers who are faced with addressing the increasing burden of complex polypharmacy.
- ● Patients should be supported by an effective prescribing team working in close partnership to ensure they are aware of the purpose of all medications taken, their likely benefits and potential risks.
- ● At the prescribing level: pharmacist/nurse to ensure appropriate medicine, dose, route and duration written for the right patient in the prescription by a certified medical practitioner.
Systems Factors
Systems factors (work environment) include the hospitals and high-risk situations within those settings (e.g. risks associated with perioperative or neonatal care). The environment in hospitals can contribute to error-provoking conditions. The clinical ward may be busy or understaffed, contributing to inadequate supervision or failure to remember to check important information. Interruptions during critical processes (e.g. administration of medicines) can also occur, which can have significant implications for patient safety. Tiredness and the need to multitask when busy can also contribute to medication error.
Strategies to reduce medication errors related to systems factors
- ● Developing a plan to achieve those objectives, including the processes, systems, patient involvement and training of healthcare professionals.
- ● Automated healthcare technologies are the greatest potential for dramatically reducing the incidence of harm caused by medication-related errors in the work environment
- ● Tables giving information on drug–drug interactions, and interactions with traditional and complementary medication are also helpful, particularly in situations where polypharmacy is common.
- ● Prescribing assessment tools can also be helpful. Building on the original Beers Criteria (for potentially inappropriate medication use in older adults), the STOPP (Screening Tool of Older Person’s Prescriptions) criteria has been developed to highlight potentially inappropriate medications.
- ● Developing a plan to achieve those objectives, including the processes, systems, patient involvement and training of healthcare professionals.
Conclusion
Medication errors account for 50% of all preventable medical harm globally. It is an area that requires urgent actions by all stakeholders. Appropriate strategies should be implemented to reduce medication errors in high-risk situations involving medication factors, provider and patient factors, and systems factors. These strategies can form part of your organization’s patient safety programs to reduce the risk of medication errors, supported by a strong patient safety and reporting culture, along with training and feedback loop.
QUASR incident reporting system has built-in incident types including medication errors. It has pre-configured forms to capture the type of medication error, severity, type of medication/ substance involved, incorrect action, incorrect dose, and other relevant information. These forms are easily configurable to suit various healthcare settings. Hospital management can gain useful and actionable insights from the medication error reported and dashboards generated.
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Empowering Medication Error Reporting with QUASR
QUASR is a cloud-based healthcare incident reporting system. It offers functionalities that encourage ME reporting, facilitate collaboration, enable analysis, and track actions. QUASR’s ME form is designed in stepper form format with skip-logic condition, making it quick and easy to report MEs. The questions are based on guidelines and industry best practices on ME reporting. The form is easily configurable to meet specific requirements. Users are guided throughout the form to ensure all relevant data is entered. Click the link below to find out!
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