Tackling Medication Prescribing, Administration, and Management/Monitoring Errors in Hospitals

Laura M. Cascella, MA, CPHRM

Medication treatment is a complex process, particularly because of the number of steps and individuals involved, the volume of medication orders in hospitals, and the increasing number of prescription medications on the market. Although errors are common throughout the medication process, the prescribing, administration, and management/monitoring stages are particularly risky in hospitals.¹

Many hospitals have implemented safety technologies — such as computerized provider order entry (CPOE), pharmacy information systems, bar-coded medication administration, automated dispensing cabinets, and smart infusion pumps — to help detect and prevent medication errors. CPOE systems, for example, address errors related to medication order illegibility, delays, inaccurate transcription, and lack of standardization. These systems often are integrated with an organization’s electronic health record (EHR) system and include clinical decision support capabilities to further enhance safety.³

However, medication safety technologies do not completely eliminate errors or guarantee patient safety. In fact, these systems might introduce new patient safety concerns and opportunities for error. CPOE, for instance, can increase clinician workload, decrease efficiency, inundate users with alerts, and result in overreliance on the system — all of which can increase the risk of medication oversights and lapses.⁴

Other medication safety systems also can have unintended consequences. ECRI’s Top 10 Health Technology Hazards for 2021, 2020, and 2019 note risks associated with system drug entry fields that populate after only a few letters are entered, dose timing discrepancies due to EHR settings and defaults, fatigue as a result of numerous system alarms/alerts, and wrong-field confusion errors with infusion pumps.⁵

Ultimately, how well medication safety technologies work depends largely on effective design, appropriate implementation, and educated users. To achieve the full benefits of these systems and reduce avoidable risks, hospitals can employ a number of strategies. For example:

• Thoroughly research system options and perform due diligence when selecting technology vendors. Include representative providers and staff members who will be using the system in evaluation activities.
• Seek input from providers and staff members to fully assess and understand their needs and workflow patterns and to solicit support for developing policies and procedures.
• Carefully plan implementation initiatives, and be realistic about the time and resources required for safe and effective implementation. Try to minimize workflow disruptions during implementation, and provide ongoing assessment and adjustment once a system is in place.
• Consider using simulation testing with new technologies to identify potential problems, unintended consequences, and workarounds that might lead to adverse drug events (ADEs).
• Develop clear policies for transitioning data between systems and for reconciling information in new systems. Establish firm expectations related to appropriate use of each system.
• Provide training and education during implementation and after to help providers and staff acclimate to new systems, recognize potential process or system problems, and work toward reasonable solutions.
• Develop a plan to (a) ensure ongoing assessment of medication technologies,
  (b) review user competency with various systems, and (c) identify errors and near-misses associated with medication technologies and determine reasonable mitigation strategies.⁶

Hospitals also can implement nontechnical strategies to prevent medication errors and reduce liability exposure. Having thorough guidelines and protocols for all steps in the medication process — including prescribing, administering, and managing/monitoring medications — will help establish safety goals and expectations. Below are additional medication-related strategies to improve patient safety and reduce the risk of ADEs:

• Ensure that providers who are involved in medication-related tasks are legally permitted by state law to perform these activities and are properly trained and credentialed.
• Maintain adequate and up-to-date drug references and resources. Providers should be aware of these resources and have easy access to them.
• Ensure that all medication-related policies and procedures adhere to state and federal regulations and accreditation standards, and that guidance supports evidence-based best practices.
• Develop and implement standard policies and procedures for medication reconciliation during admission, handoffs, and discharge.
• Establish a list of potentially problematic abbreviations, symbols, and dose designations. The Institute for Safe Medication Practices (ISMP) offers a detailed and up-to-date List of Error-Prone Abbreviations.
• Ask providers and staff to be aware of the list of error-prone abbreviations, symbols, and dose designations and to avoid them when communicating medical information to patients, pharmacists, and other providers.
• Establish policies that target potential problems with drug names and dosages. For example, require providers to always include the indication for use on prescriptions and use leading zeros as the standard format for writing out dosages.
• Determine whether your organization has adequate policies and procedures for managing high-alert medications, such as anticoagulants and analgesics. Provide thorough education on procedures for prescribing and administering high-alert medications as well as for monitoring patients who receive them.
• Review organizational policies related to drug diversion and security of medications, including prescription and administration protocols, which might be vulnerable to diversion attempts.
• Limit the use of verbal medication orders (in-person or via phone) to emergency situations. When possible, verbal orders should be read back to confirm accuracy.
• Assess provider workflows and identify strategies to improve administration safety, such as limiting interruptions, standardizing processes, using independent double-checks for high-alert medications, and implementing medication safety rounds.
• Implement medication administration policies that require providers to:
  • Verify the patient’s identity using at least two unique identifiers.
  • Verify the correct drug, dose, route, and time for administration.
  • Check the medication label against the medication order.
  • Visually inspect the medication and verify its expiration date.
  • Check for contraindications or potential drug interactions.
• Train providers and staff members on infection prevention and control procedures for medication preparation and administration, including safe injection practices.
• Develop policies and procedures for monitoring patients’ responses to new medications and changes in medication regimens. Train staff to identify common adverse medication effects and react appropriately using specified pathways.
• Work with physicians, nurses, pharmacists, and laboratory staff to develop guidelines for the correct timing of blood collection for medication monitoring. Identify critical values that should trigger electronic alerts to providers.
• Educate patients about their medications, including their purpose, appropriate use, and potential side effects. Use language and materials that take into account patients’ health literacy and comprehension levels. To ensure understanding, consider asking patients to repeat back, in their own words, the information they have received about their medications.
• Ensure your organization has thorough policies for error reporting and root cause analysis. Support a nonpunitive culture in which providers and staff members are encouraged to report medication errors and near misses.⁷

For more information about technical and nontechnical strategies for reducing medication prescribing, administration, and management/monitoring errors in hospitals, see HealthIT.gov’s SAFER Guides, the ISMP’s Targeted Medication Safety Best Practices for Hospitals, the Agency for Healthcare Research and Quality’s Patient Safety Network, and the American Society for Health-System Pharmacists’ Guidelines on Preventing Medication Errors in Hospitals.

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¹ Institute of Medicine. (2006). Preventing medication errors. Washington, DC: National Academies Press; CRICO Strategies. (2016). Medication-related malpractice risks: CRICO 2016 CBS Benchmarking Report. Retrieved from www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Medication

² CRICO Strategies, Medication-related malpractice risks: CRICO 2016 CBS Benchmarking Report.

³ ECRI. (2020, June 3). Implementing computerized provider order entry. Health System Risk Management. Retrieved from www.ecri.org/components/HRC/Pages/Pharm6.aspx

⁴ Agency for Healthcare Research and Quality. (2017, June). Patient safety primer: Computerized provider order entry. Retrieved from https://psnet.ahrq.gov/primers/primer/6/computerized-provider-order-entry

⁵ ECRI Institute. (2018). 2019 top 10 health technology hazards: Executive brief. Retrieved from www.ecri.org/top-ten-tech-hazards; ECRI Institute. (2019). Top 10 health technology hazards for 2020: Executive brief. Retrieved from www.ecri.org/landing-2020-top-ten-health-technology-hazards; ECRI. (2021). Top 10 health technology hazards for 2021: Executive brief. Retrieved from www.ecri.org/2021-top-10-health-technology-hazards-executive-brief

⁶ Office of the National Coordinator for Health Information Technology. (2019). Electronic health records (Section 1). In Health IT Playbook. Retrieved from www.healthit.gov/playbook/; Agency for Healthcare Research and Quality, Patient safety primer: Computerized provider order entry; Agency for Healthcare Research and Quality. (2019, September 7). Patient safety primer: Human factors engineering. Retrieved from https://psnet.ahrq.gov/primer/human-factors-engineering; ECRI. (2020, April 23). Technology for medication safety. Health System Risk Management. Retrieved from www.ecri.org/components/HRC/Pages/Pharm2.aspx

⁷ Institute of Medicine, Preventing medication errors; Agency for Healthcare Research and Quality. (2019, September 7). Patient safety primer: Medication errors and adverse drug events. Retrieved from https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events; Agency for Healthcare Research and Quality. (2021, March 12). Patient safety primer: Medication administration errors. Retrieved from https://psnet.ahrq.gov/primer/medication-administration-errors; ECRI Institute. (2017, November 6). Medication safety. Healthcare Risk Control. Retrieved from www.ecri.org/components/HRC/Pages/Pharm1.aspx; ECRI Institute. (2015, September). Self-assessment questionnaire: Medication safety. Health System Risk Management. Retrieved from www.ecri.org/components/HRC/Pages/SAQ31.aspx; Billstein-Leber, M., Carrillo, C., Cassano, A. T., Moline, K., & Robertson, J. J. (2018). ASHP guidelines on preventing medication errors in hospitals. American Journal of Health-System Pharmacy, 75(19), 1493–1517. https://doi.org/10.2146/ajhp170811

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