Table of Contents
1) Areas in Which Medication Errors Occur
2) Documenting – Sources of Error
a) Allergies – Preventative Actions
b) Adverse Reactions - Preventative Actions
3) Prescribing - Sources of Error
a) Incorrect Dosage Strength or Route of Administration - Preventative Actions
4) Dispensing - Sources of Error
a)Improper Preparation - Preventative Actions
b) Dispensing the Wrong Medication - Preventative Actions
5) Reflection
6) Sources
Documentin
g
Areas in Which Medication
Errors Occur
Prescribing
Dispensing
Documenting
Possible Sources of Error
x An allergic reaction to an active or inactive
ingredients within the medication
x Allergies to certain materials used in
preparation process
x Adverse drug reactions
Allergies – Preventative Actions
 A patient should keep a complete log of his or her allergies in order to ensure
accurate filling of documents while at the doctor’s office or at the hospital.
 A doctor should leave a note when ordering a medication from the pharmacy in
order to ensure the drug is prepared in compliance to the patient’s profile.
 A pharmacist should place auxiliary labels on all drugs that were made using a latex
free method.
 A nurse should double check the patients record for any allergies before the
administration of any drug.
Adverse Reactions – Preventative Actions
 A hospital, pharmacy, or doctor’s office should have a chart identifying all drugs
and the drugs they interact with accessible to all.
 A patient should keep a record of all of the medications they are currently using
and medications used in the past to ensure a new drug does not have adverse
effects.
 A hospital should implement a computer system in which the program alerts the
doctor of any adverse reactions when placing an order.
Prescribing
Possible Sources of Error
x Incorrect dosage strength could be ordered
x Incorrect route of administration could be
prescribed
Incorrect Dosage Strength or Route of Administration
– Preventative Actions
 A hospital should implement a computer system that requires a double check on
drugs that have multiple dosage strength options.
 A doctor should always make sure to order the quantity that allows the patient
to take the least amount of tablets.
 A doctor, pharmacist, or nurse should review all patient history to assure the
patient has no history of problems with a certain route of administration.
 A patient should familiarize themselves with different routes of administration
in order to ensure compliance.
• For example, if not comfortable with swallowing pills, a patient should ask
the doctor for alternatives.
Dispensing
Possible Sources of Error
x Improper sterile or non-sterile preparation of a drug
x The wrong medication, strength, or dosage form dispensed
Improper Preparation
 All staff involved in the preparation of sterile medications should undergo
proper training and testing under USP <797> guidelines.
 All health care providers should implement a “buddy system”. They should
check each others work to make sure that the right ingredients are being added,
and provide a double check on all calculations and measurements.
 All staff, when working with drugs that contain ingredients that patients
commonly have allergies to (sulfur, penicillin, etc.), should wear gloves.
Dispensing the Wrong Medication
 A Look-Alike Sound-Alike (LASA) chart should be available to all employees and patients
in any health care setting.
 Pharmacists or technicians should place auxiliary labels on bottles or shelves containing
medications that are found on the LASA chart.
 Tall man lettering should be implemented in drugs that show similarity in spelling to
other medications.
• For example, buPROPion vs. busPIRone.
 All high-risk drugs should be labeled as such to ensure all staff handling these
medications never dispense them accidentally.
 A drug that comes in different dosage strengths or dosage forms should require a barcode
scan when entering or taking out the medication from an automated dispensing machine.
Reflection
As a co-op student at Beth Israel Deaconess, the main objective of the entire institution was to maintain the
highest level of patient care. In the pharmacy department, our way of achieving this goal was to reduce medication errors
that could be prevented on our end. This really intrigued me to research this topic because these errors have the potential
to cause a lot of harm or could even be fatal. I wanted to put together a presentation that offers recommendations that
could be used by any health care professional.
I chose a Powerpoint Presentation because allowed me to get the most amount of information in a manner that
flowed well. I wanted to separate the information in a way that makes sense, and makes it easy to get to the information
you need without sieving through a lot of information. The presentation begins with a table of contents which makes
organization clear to the audience. Each slide is also hyperlinked to the table of contents and can be accessed with one
click. By choosing a simple and neutral layout and color scheme, my goal was to make it very easy on the eyes. The use of
visuals also allows the user to stray from being bored and straining their eyes. I refrained from using visuals on the
preventative action slides because I want the audience to be more focused on the text as it is the central idea of my
presentation. The information is separated into different parts of patient care process where errors could occur. I then
further broke it down into possible sources of error (marked by X’s) in that area and then offered suggestions for these
sources (marked with checkmarks). I used color coordination to facilitate organization and keep all the information
together.
I can see this Powerpoint or separate slides of the presentation hanging up in a pharmacy, doctors office, nurses
station. I could also see a nurse, pharmacist, or even a doctor presenting this as a continuing education topic to their peers.
Sources
FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters. (n.d.). ISMP.
Retrieved October 12, 2013, from https://www.ismp.org/tools/tallmanletters.pdf
Leach, H. (n.d.). High Risk Medications - Feeling the PINCH!. A Victorian Government Initiative .
Retrieved October 11, 2013, from docs.health.vic.gov.au/docs/doc/
053C11504F0A5A5ECA257A17001EC78D/$FILE/pinch_presentation.pdf
Look-alike/sound-alike drug list | Joint Commission. (n.d.). Accreditation, Health Care, Certification
|
Joint Commission. Retrieved October 13, 2013, from
http://www.jointcommission.org/LASA/
Medication Errors Associated with Documented Allergies. (n.d.). Pennsylvania Patient Safety
Authority. Retrieved October 12, 2013, from http://patientsafetyauthority.org/ADVISORI
Nelson, A., Nguyen, G., & Pham, D. (n.d.). Roundup: Preventing Medication Errors in Health
Systems. Pharmacy Times - Practical Information for Today's Pharmacist. Retrieved
October 13, 2013, from http://www.pharmacytimes.com/publications/issue/
2008/2008-07/2008-07-8601
**Note – I believe
that this piece will
fit perfectly into my
professional
portfolio. I think
that both the visual
and textual content
are on a
professional level
which would be a
good fit for the
portfolio.