Ensuring that medications are given safely and accurately is a cornerstone of safe medical care. The importance of following the “Five Rights” of Medication Administration (right patient, drug, dose, route, and time) is ingrained in every medical, nursing, and pharmacy student’s training.
Yet, the Institute of Medicine’s (IOM) groundbreaking report, To Err Is Human: Building a Safer Health System, noted that medication-related errors were a significant cause of morbidity and mortality, accounting for one out of every 131 outpatient deaths, and one out of 854 inpatient deaths. Despite the implementation of quality improvement programs, error reduction efforts, and new technologies, medication administration errors in US hospitals and healthcare organizations remain a serious safety problem.
For instance, in a review of 91 direct observation studies, investigators estimated the median error rate of medication administration is 8%–25%, depending on the measurement strategy and whether or not timing errors were included. The estimated median rate (including timing errors) of intravenous administration was even higher, ranging from 48%–53%. The most common type of error was wrong time of administration, followed by omission and wrong dose, wrong preparation, or wrong administration rate (for intravenous medication).
There are many strategies and tactics for improving the safety of medication administration. Here are five that can make an impact.
1. Assess the work environment
Medication administration mistakes and other safety issues can increase when certain work environment conditions are present. These include persistent staff shortages or turnover, too many distractions and interruptions, poorly designed medication safety protocols, and failure to adhere to policies and guidelines.
Although most hospitals and healthcare systems have set various quality improvement initiatives in motion over the last 20 years, when was the last time yours took a specific look at the environmental factors that could impact safe medication administration? Are you confident that all shifts are staffed appropriately for maintaining high safety standards and reducing fatigue that can cause a mistake? Are workflows set up to minimize distraction during medication administration? Are guidelines and decision-making protocols up to date, properly followed, and designed to maintain safety standards? If you aren’t sure of the answers, it’s time to assess the work environment and its impact on the organization’s medication administration protocols and policies.
2. Implement medication safety technologies
Computerized order entry, medication safety alerts, medication and patient barcoding, smart infusion pumps for intravenous administration (IV), single-use medication packages - these are all examples of technologies that can reduce or prevent medication administration errors. Used in conjunction with effective processes, properly trained staff, and an environment with minimal distractions, such technologies can very effective.
Barcode medication administration, for example, has been shown to essentially eliminate wrong patient, medication, and dose errors in inpatient settings. One study of nontiming medication errors in a system with comprehensive barcoding/electronic medical administration technology found a 41% reduction in errors and a 51% decrease in potential adverse drug events. Timing errors were also reduced by 27% in this institution.
But although technology is certainly useful when combined with effective guidelines and protocols, it’s not a panacea. There are still human elements to the medication administration process that have to be considered. When a patient’s wristband won’t scan, or a medication isn’t listed in the system or there is an equipment malfunction, nursing staff and clinicians implement workarounds to complete their tasks, which can actually increase the risk of error.
3. Educate patients and caregivers
Patients and caregivers administering medications at home make up a large number of medication administration errors. A review of 36 studies on caregiver medication errors found error rates ranging from 2%–33%, with dosage errors, omissions, and wrong medication the most common types of administration errors.
Provide patients and their caregivers with adequate education about how to take their medicines at home, and when to contact their provider if they aren't sure how to administer it. Communicate the information verbally and in writing. Identify those who have low health literacy and take additional time to ensure they understand instructions; enlist the support of a social worker as needed.
4. Implement strategies for “LASA” drugs
Many drugs look-alike and/or sound-alike (LASA). When names, packaging, or administration device design are similar, these medications can be mistaken for each other. The Joint Commission has developed a list of the most problematic medications, here.
Misreading medication names that look similar is a common mistake, particularly in hospitals, and particularly when orders are communicated verbally. To reduce the risk of these errors, use strategies such as:
- Use “Tall Man Lettering" - which helps distinguish similar drug names
- Add warning labels that alert staff to LASA drugs
- Educate patients and caregivers about LASA drugs and how to check for them
- Configure your computerized order entry system to alert clinicians when they are prescribing drugs that look or sound similar
5. Take extra precaution with “high alert” medications
High alert medications are those more likely to cause harm or death when used in error.
According to the Institute for Safe Medication Practices (ISMP), the top five high-alert medications are insulin, opiates and narcotics, injectable potassium chloride (or phosphate) concentrate, intravenous anticoagulants (heparin), and sodium chloride solutions above 0.9 percent. ISMP’s list of high-alert medications is available here.
Some of the ways ISMP suggests that organizations can reduce the risk of error with "high alert" medications include: standardizing the ordering, storage, preparation, and administration of these mediations, limiting their use, and using automated alerts to heighten awareness when prescribing or administering them.
 Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
 Medication Administration Errors, Patient Safety Primer, AHRQ Patient Safety Network, January 2019, https://psnet.ahrq.gov/primers/primer/47/Medication-Administration-Errors
 Medication Errors: Patient Safety Primer, Patient Safety Network, Updated January 2019, https://psnet.ahrq.gov/primers/primer/47/Medication-Administration-Errors