in calling for implementation of proven medication safety practices as de

In calling for implementation of proven medication

This preview shows page 215 - 217 out of 312 pages.

in calling for implementation of proven medication safety practices as de- scribed below. Adopt a System-Oriented Approach to Medication Error Reduction Throughout this chapter, emphasis is put on the development of a system-oriented approach that prevents and identifies errors and minimizes patient harm from errors that do occur. It involves a cycle of anticipating problems, for example with changes in staffing or the introduction of new technologies, adopting the five principles described, tracking and analyzing data as errors and near misses occur, and using those data to modify pro- cesses to prevent further occurrences. None of these steps is useful alone. When taken together with strong executive leadership in a nonpunitive en- vironment and with appropriate resources, they become extremely powerful in improving safety. Implement Standard Processes for Medication Doses, Dose Timing, and Dose Scales in a Given Patient Care Unit One of the most powerful means of preventing errors of all kinds is to standardize processes. If doses, times, and scales are standardized, it is easier for personnel to remember them, check them, and cross-check teammates who are administering the medications. Standardize Prescription Writing and Prescribing Rules A host of common shortcuts in prescribing have frequently been found to cause errors. Abbreviations are the major offender because they can have more than one meaning. Other traps include the use of q ( as in qid, qod, qd, qh), which is easily misread, and the use of the letter u for unit. Failure to specify all of the elements of an order (form, dose, frequency, route) also leads to errors. Putting such information in computerized order entry forms can help eliminate such errors. Limit the Number of Different Kinds of Common Equipment Simplification reducing the number of options is almost as effec- tive as standardization in reducing medication errors. Just as with limiting To Err Is Human: Building a Safer Health System Copyright National Academy of Sciences. All rights reserved.
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CREATING SAFETY SYSTEMS IN HEALTH CARE ORGANIZATIONS 191 medications to one dose decreases the chance of error, limiting the types of equipment (e.g., infusion pumps) available on a single patient care unit will improve safety. Unless all such equipment has the same method of setup and operation, having several different types of infusion pumps and defibrillators increases the likelihood of misuse, sometimes with disastrous consequences. Implement Physician Order Entry Having physicians enter and transmit medication orders on-line (com- puterized physician order entry) is a powerful method for preventing medi- cation errors due to misinterpretation of hand-written orders. It can ensure that the dose, form, and timing are correct and can also check for potential drug drug or drug allergy interactions and patient conditions such as renal function. In one before-and-after comparison, 58 nonintercepted serious medication errors decreased by more than half (from 10.7 to 4.86 events per
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