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How to Prevent Medication Errors With Detection and Prevention

May 16, 2018

Tight schedules, resident medication changes, new admissions, new staff and more are all factors that increase working intensity and contribute to med errors. While every healthcare professional tries his or her best to practice safe medication administration, each of us is capable of making a med error. In fact, according to the US National Library of Medicine, it is believed that preventable medication errors impact more than 7 million patients across all healthcare settings and cost almost $21 billion each year.

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as a “preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of a health care professional, patient, or consumer.

Safe Medication Administration Requires an Integrated Approach

It takes an entire team of healthcare professionals working together to provide optimal care for residents. Because medication and treatment therapies happen at varying stages of patient care, med errors can occur:

  • At the time the order is written
  • In transcription
  • By pharmacy in order entry and dispensing
  • In delivery or distribution
  • During administration 

The Importance of Safe Medication Administration

Through compassionate and diligent care we’re all able to provide great care to residents and members of LTC communities who put their trust in us. It is also why our HealthDirect team implements pharmacy management solutions with the latest prescription technology. This technology ensures accuracy, customization and efficiency; all of which are essential in avoiding common medication errors.

Reasons for Common Medication Errors

Education is the key to prevention. Through education, all healthcare professionals can practice safe medication administration by being aware of practices that lead to common medication errors. However, despite our best efforts, med errors in nursing homes and LTC communities can occur at any time. Common reasons for mediation errors include:

  • Confusing drugs that sound or look alike
  • Poor or lost communication
  • Dose miscalculations
  • Unclear orders
  • Incorrect facility or patient
  • Confusing use of abbreviations and symbols
  • Illegible handwriting
  • Mislabeling
  • Incorrect storage, method of delivery or omission             

Significant Med Errors in Nursing Homes

While all med errors should be avoided, any med error that causes the resident discomfort or jeopardizes his or her health and/or safety is considered significant. Bear in mind that each resident’s experience is individualized. This means “discomfort” is a relative term and subject to personal perception. Diligence is needed to avoid the mistake but, if an error occurs, immediate corrective action must be taken. These actions include proper reporting, assessment and resident evaluation and, if needed, treatment.

Best Practices: Prevent and Reduce med errors in nursing homes and LTC Communities

There are many healthcare workers involved in various aspects of resident care. This can make practicing safe medication administration complex. HealthDirect simplifies this for facilities with industry-leading pharmacy solutions tailored to individual facility needs. Additionally, there are standards and tools available to minimize the risk of administering incorrect medication. These include:

  • Computerized systems
  • Compatible systems for medical record exchange
  • Automated dispensing devices and compliance packaging
  • Uniform standards of writing orders
  • Adequate training and educations of all staff
  • Competency tests
  • Routine observations of med passes

Staff should also have knowledge and training of:

  • Indications for use, precautions and contraindications
  • Expected outcome from use
  • Potential adverse reactions w/food or other meds
  • Action to take when medications interactions are suspected
  • Storage requirements of medication

Adopt a Safety Culture

Promoting medication safety acknowledges that reading every label, reading every direction and following every order takes time and diligence. But, in the long run, it promotes safety, wellness and overall efficiency. Focusing on safety ensures every resident is entitled to the “five rights”:

  • Right drug
  • Right dose
  • Right resident
  • Right time
  • Right route

 “At Risk” Behaviors

Some “at-risk” behaviors known to increase the likelihood of medications errors include:

  • Keeping unused meds from discharged patients
  • Not properly discarding discontinued meds
  • “Borrowing” medications from one patient for another
  • Carrying medications in uniform pocket
  • Removing meds/preparing meds before reaching patient bedside
  • Administering med without fully reading the label
  • Placing more importance on financial criteria than patient safety
  • Overusing stat order as a workaround

In contrast, there are “best practices” for safe medication administration, which reduce the risk of med errors in nursing homes.    

  • Always read the label and MARs 3 times during preparation
  • Correctly identify the resident before administering
  • Monitor resident for effectiveness and possible adverse reactions
  • Slow down—rushing nearly always results in delays

How to prevent medication errors: Partner with a trusted pharmacy

For more than 50 years, HealthDirect has been a trusted partner in helping facilities provide residents with the right dose, for the right patient, at the right time. We believe in making pharmacy solutions accurate, efficient and tailored to meet the needs of the residents and healthcare professionals we serve. By integrating the industry’s best practices, including technology advancements, we help to reduce the risk of med errors in nursing homes. Our Long Term Care Pharmacy Commitment is designed with your facility, and your residents, in mind.

Develop your customized medication error prevention by partnering with HealthDirect.  Call us at (888) 708-3999. Our knowledgeable team is available from Monday – Friday, 8:00am to 4:30 pm EST. Or, if you prefer, visit our contact page.


Additional Sources:

Pizzolanti, Jan. Medication Error DetectionMedication Error Detection, RX Consults, 2016.

rxr@usp.org. “About Medication Errors.” NCC MERP, 30 Jan. 2015, www.nccmerp.org/about-medication-errors.

Silva, Brianna A. da, and Mahesh7 Krishnamurthy. “The Alarming Reality of Medication Error: a Patient Case and Review of Pennsylvania and National Data.” Journal of Community Hospital Internal Medicine Perspectives, Co-Action Publishing, 7 Sept. 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5016741/.

Brandi VanValkenburg

Brandi provides personalized care as a pharmacy consultant with HealthDirect's northeastern region.  She's been serving our clients for nearly 10 years. 

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