What are the best ways to prevent medication administration errors?

1-Double-checking medication orders: Two healthcare professionals should independently check all medication orders before they are dispensed or administered. 2-Using barcode scanners: Barcode scanners can be used to verify that the correct medication is being dispensed and administered to the correct patient. 3-Using medication carts: Medication carts can be organized to help healthcare professionals find the correct medications quickly and easily. 4-Using standardized labels: Standardized labels can help to prevent medication mix-ups. 5-Taking breaks and avoiding distractions: It is important for healthcare professionals to take breaks and avoid distractions when administering medications.

I would establish a culture where healthcare professionals can confidently report near-miss incidents and errors, free from the fear of punitive consequences. Leverage these reports as chances for learning and process enhancement instead of attributing blame. This approach promotes transparency and the recognition of system vulnerabilities. It is also can be helpful, if you create and put in place uniform communication protocols for conveying medication-related information. Moreover I would employ Poka-yoke (mistake-proofing solutions) to proactively prevent errors in medication administration.

Informatics and analytics can help reduce the impact of MAEs. Medication errors are commonly underreported by health care personnel, leaving future patients at risk. By searching the medical records of thousands of patients, the pharmacy informatasist can look for medications that are frequently known to cause errors and look for the medication that is commonly used to counteract the effects of the offending medication. If the two medications are on a patient's medication administration record within a certain time window, we can infer that an error has occurred. With these data, the hospital now has valuable information, to educate, implement policy and further guard against patient harm.

As an HCP who prepared and also administered meds you need: - correct staffing levels at the pharmacy and bedside - electronic records systems with patient specific bar codes tied to smart (live) patient records, connected medicine dispensers (e.g, Pyxis), and multiple layers of validation in the pharmacy & at the bedside. - real time verification of drug interactions & patient health contradictions imbedded in hospital drug ordering systems

In my experience this is the least utilized and one of the most powerful methods of preventing MAEs in conscious and cooperative patients. Another important thing to keep in mind is the language barriers and use of appropriate language banks to confirm understanding by the patients.

There are several ways to educate and empower patients to prevent medication administrative errors, but one of the most efficient is through the use of patient education materials. These can include pamphlets, infographics, and online resources that provide information about medication safety and how to prevent errors. They can also include interactive tools, such as web-based or mobile apps, that allow patients to track their medications and get reminders about dosages and side effects, available in multiple languages, so that patients with limited English proficiency can still access them.

Empowering patients in their medication management is not just a method; it's a mindset. When patients are educated and involved, we create a partnership in care that leads to better outcomes and a more patient-centered approach. It's not just a strategy; it's a philosophy that enhances healthcare.

One of the strange tools is "not to always write administration on the box". It is quite relevant to talk about drugs for which the administration has changed or new drugs. It is not that relevant to repeat the full administration scheme at the pharmacy. This seems somewhat unorthodox and dangerous even. However, in Estonia there are repeated prescriptions. And often there are cases where administration scheme has changed, but it has not been updated on prescription, because prescription has been extended by nurse who does not change doctor's words. So it is fine of course to write everything on box. But pharmacist cannot actually be sure of the regimen.

Educating and empowering patients is a transformative force in healthcare. 🌟 When patients understand their conditions, treatment options, and the importance of preventive care, they become partners in their own health journey. Empowered patients actively engage in decision-making, ask questions, and adhere to treatment plans. This not only leads to better health outcomes but also reduces the burden on the healthcare system. Education and empowerment are keys to unlocking healthier, more informed, and proactive patient communities. 🤝💙 #PutPeopleFirst #PrioritozePatientCare # PursuingProfitabilitywithPurpose #PatientEmpowerment #HealthEducation #PatientCentricCare

1. Encourage Reporting Create a culture where staff feels safe reporting errors. Use root cause analysis to understand why the error occurred. 2. Communicate the error internally among the team. Open discussions can facilitate collective learning. 5. Develop and implement action plans to prevent similar errors in the future. This might involve process improvements, additional training, or new protocols. 6. Feedback Loop: Ensure that the lessons learned are fed back into training and quality improvement initiatives, closing the loop on continuous learning. Reporting and learning from errors is a proactive way to enhance patient safety and improve the quality of care. It's a cornerstone of a high-reliability healthcare system. 🏥📊

Preventing MAEs involves fostering a culture of safety and transparency that encourages error reporting without fear of blame. It also requires analyzing errors to identify root causes and contributing factors, implementing corrective actions, and sharing lessons learned. Continuous education and training on medication safety are vital. These steps collectively enhance patient safety and minimize the occurrence of MAEs in healthcare.

I will add to this post that a timely review of incidents is also important. Let’s not forget about taking the time to analyze trends.

RCA and PSIRF need to look at the actual root causes, not the errors. Errors do not cause harm. They let hazards go through to cause harm to patients. We can only learn if we know what the hazards are and how to stop them from moving through.

With the increasing awareness, the reporting of errors, its analysis and education have improved in most organizations over the last decade. The top leadership should take complete responsibility to provide and continuously evaluate and improve the "just culture of safety" in their organization. Anonymous reporting systems is must and should be encouraged to prevent the fear of blame.

An IT system that can work in a joined up fashion that allows complete access to patients information regardless of health journey i.e. primary, secondary or tertiary level care. No more missing information or gaps in knowledge, the ability to see not only the appropriateness of prescribing but also the complete concordance of a patient.

Nas situações em que é realizada a prescrição verbal (como em uma situação de urgência por exemplo), a técnica “read-back”, que basicamente consiste em repetir o que foi dito, pode ser utilizada como uma ferramenta para evitar erros de administração de medicamentos, pois ao repetir o que se ouviu, caso haja uma falha no entendimento, está pode ser corrigida. Essa técnica pode evitar erros principalmente nos medicamentos “sound-alike”, aqueles que possuem nomes com sonoridade parecida.

Medication administration by the nurses is the last leg of the journey that starts with a detailed history taking by the physician, complete medicine reconciliation by the physician and the pharmacist and so on. Its a complete team work and hence any learning should be shared with all the stakeholders at all times. In my view we should involve the medical students, nursing students and pharmacy students early in these communications and learnings.

To prevent medical administration errors, it is important to have a culture of openness where healthcare professionals can report errors without fear of retribution. Regular analysis of medical errors can identify patterns, leading to targeted interventions to reduce the risk of future errors.

Augmented reality-based medication guidance (AR glasses and applications) could guide healthcare professionals through the medication administration process, displaying relevant information and instructions in real time.

As ferramentas da qualidade como indicadores, podem ser utilizadas para esclarecerem oportunidades de melhoria. Como por exemplo, se observado que há um percentual elevado de EAM com determinado medicamento ou determinada unidade, pode ser elaborado um plano de ação e treinamento específico. “Não se gerencia o que não se mede, não se mede o que não se define, não se define o que não se entende e não há sucesso no que não se gerencia.” William Edwards Deming

use quality improvement tools to monitor and evaluate your medication management practices. You should have indicators and measures that assess the frequency, severity, and types of MAEs and their impact on patient outcomes. You should also have audits and feedback mechanisms that check the compliance and performance of your protocols and procedures. You should also use quality improvement methods, such as Plan-Do-Study-Act cycles, to test and implement changes and innovations that enhance medication safety.

One thing to keep in mind regarding the KPIs and measures is to keep reviewing them for their relevance. Change the measures or frequency of monitoring where the data is showing sustained results/targets for 6 months or more. Use appropriate sampling methodology for audits of high volume of data. And most important of all, do a detailed mapping of your process in your respective organization before you think of making any changes.

Digital systems that incorporate clinical and safety functions to eliminate potential risks. These include clinical alerts for ADR, or allergies. Clinical decision support tools to aid dosing and to check for interactions. Automated calculations of infusion rates or dose unit conversions. Quality improvement reporting with medication use analysis

Realize conciliação medicamentosa em todas as transições de cuidados como admissão, transferência e alta do paciente, para garantir a continuidade e precisão das prescrições. Além de ser imprescindível ter um farmacêutico clínico/ assintencial junto ao paciente e equipe multiprofissional.

A possibilidade de se utilizar no sistema informatizado de prescrição, gatilhos de alertas e informações adicionais à prescrição para ciência da equipe multidisciplinar pode reduzir a possibilidades falhas. A presença do Farmacêutico Clínico próximo à equipe multidisciplinar, presencialmente, traz benefícios como dirimir possíveis dúvidas, participar das discussões técnicas e visualizar oportunidades de treinamento no processo do uso do medicamento.

Existem várias estratégias eficazes para prevenir erros na administração de medicamentos: 1. Verificação de Identificação; 2. Dupla Verificação; 3. Uso de Tecnologia; 4. Educação e Treinamento; 5. Comunicação Eficaz; 6. Revisão da Prescrição; 7. Monitoramento Regular; 8. Farmacêutico Clínico; Implementando essas medidas preventivas, você pode ajudar a garantir uma administração de medicamentos segura e eficaz.

AI is still a relatively new technology, but it has the potential to revolutionize medication safety practices. By using AI to identify and predict MAEs, develop and implement medication safety interventions, and monitor and evaluate medication safety practices, healthcare organizations can create safer and more reliable medication management systems for all patients.