Medication Error Prevention in Hospitals Guidelines (2018)

American Society of Health-System Pharmacists (ASHP)

Reviewed and summarized by Medscape editors

November 05, 2018

The guidelines on the prevention of medication errors in hospitals were released on October 1, 2018, by the American Society of Health-System Pharmacists (ASHP).[1]

The American Society of Health-System Pharmacists (ASHP) guidelines on preventing medication errors in hospitals lays a framework in which pharmacists are provided guidance and best practices in order to proactively, rather than reactively, prevent and mitigate harm due to medication errors in health-system settings. These comprehensive guidelines provide recommendations for each step in the medication-use system, as follows:

  1. Planning

  2. Selection and procurement

  3. Storage

  4. Patient admission

  5. Ordering, transcribing, reviewing

  6. Preparing

  7. Dispensing

  8. Administration

  9. Monitoring

  10. Patient discharge

  11. Evaluation

Planning for Safe Medication Practices

Medication safety should be prioritized at both an organizational and departmental level, and a system for supporting medication safety should be established. Essential to this framework are appointment of a medication safety leader, established steps to ensure medication safety, and a strategic plan.

Selection and Procurement

This step involves identifying which medications are needed at the institution (the formulary) followed by safe procurement of those medications.

Decreasing the likelihood of errors during medication selection and procurement is composed of five elements, as follows:

  • Formulary assessment and management

  • Standard concentrations

  • Safety alert monitoring

  • Safe procurement

  • Medication shortage management

Storage

Medications should be arranged and stored carefully to reduce the likelihood of medication errors; minimize the likelihood of unintended selection of the wrong product or dosage form in the pharmacy as follows:

  • Employ bar-code or radio-frequency identification (RFID) scanning to reduce dispensing errors.

  • Adequate space should be provided for each medication and strength.

  • Bottle labels should face forward.

  • Each dosage form or administration route should be kept in separate areas.

  • Frequently confused pairs should be separated.

  • High-alert medications and look-alike and sound-alike (LASA) medications should be segregated.

  • Labeling and alerts should be used, when appropriate.

Patient Admission

A medication history and medication reconciliation must be obtained for patients upon admission. The pharmacy should be involved in procuring an accurate medication history. This process should be standardized across the institution.

Ordering, Transcribing, Reviewing

Ordering

Providers must consider numerous steps when medications are ordered, as follows:

  • Patient assessment

  • Diagnostic or monitoring tests

  • Diagnoses

  • Patient history

  • Appropriate selection and dose of medication

  • Concomitant therapies

  • Therapy duration

An error during any of these steps could result in an adverse drug event (ADE).

Current pharmacotherapy practices and clinical practice guidelines should be referenced when new or additional medications are prescribed, and the patient's health status and existing drug therapy should be reviewed.

Transcribing

Factors that contribute to transcribing errors are as follows, and avoidance steps should be taken:

  • Incomplete or illegible prescriber orders

  • Incomplete or illegible nurse handwriting

  • Use of error-prone abbreviations

  • Inappropriate defaults in electronic health records (EHRs)

  • Lack of familiarity with drug names, doses, or frequencies

Environmental safeguards include keeping the transcription area well-lit and quiet to reduce distractions. EHRs with computerized physician order entry (CPOE) reduce the risk of transcription errors. Reduce the use of handwritten orders, verbal orders, and standardized order sets, when possible.

Reviewing

A pharmacist must review medication orders to ensure appropriateness before medications are prepared or dispensed, with few exceptions. Common errors to avoid during the review process are as follows:

  • Incorrect drug

  • Incorrect dose

  • Incorrect patient

  • Incorrect route

  • Incorrect rate

  • Incorrect diluent

  • Incorrect dosage form

  • Incorrect time

  • Missed allergy

Preparing

Medication preparation should be conducted in an environment with proper conditions (ie, sanitary, well-lit, appropriate temperature, appropriate moisture, well-ventilated, segregated, and secure).

Dispensing

A pharmacist (or advanced pharmacy technician with proper qualifications and training) should review all medications in nonemergent situations before dispensation. The original medication order should be reviewed. At minimum, a self-checking process should be undertaken in reading prescriptions, labeling, and dosage calculations. High-risk drug products (eg, chemotherapeutic agents, medication for children, total parenteral nutrition [TPN]) should be checked independently by a second individual, preferably another pharmacist at a different time. In particular, the drug, labeling, packaging, quantity, dose, and instructions should all be confirmed as accurate.

Administration

The list of safeguards for administering a medication is continually evolving but is based on the "5 Rights of Medication Administration" (ie, the right patient, the right drug, the right dose, the right route, and the right time).

Barcode medication administration (BCMA) can facilitate safe medication administration. If smart infusion pumps are used, the concentrations of medications should be standardized, the interoperability options between pumps and other technology should be evaluated, the lower and upper dosing limits should be set, and soft and hard limits should be used carefully. Additional priorities in terms of administration include educating both the practitioner and the patient (when possible) on correct procedures to prevent medication errors.

Monitoring

Priorities in medication monitoring include the following:

  • Monitor the medication effects

  • Correctly interpret laboratory data used to monitor medication effects

  • Correctly transcript laboratory values

  • Monitor at the correct times

  • Monitor serum concentrations at the correct times

Patient Discharge

To facilitate good outcomes, pharmacists should educate and counsel patients upon discharge to motivate and prepare them to adhere to their medication regimens and monitoring plans. Emphasis should be placed on the following:

  • Ensure that patients are prepared to obtain their medications (drug availability, personal transportation, insurance coverage).

  • Ensure that patients understand how to schedule follow-up appointments and laboratory visits.

  • Ensure that patients are discharged with all prescribed medications and/or necessary equipment.

  • Ensure that patients know how to take their medications.

  • Ensure that patients know which pre-hospitalization medications should be discontinued.

Evaluation

Systems and processes that have been put in place to prevent medication errors should be continually evaluated and adjusted to provide optimal outcomes.

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