Medication errors in hospitals is a serious and widespread issue that can have serious consequences for both the patient and the facility. One type of preventable error that occurs is when a patient is given duplicate medication due to being transferred to another unit or because of a shift change.
An Institute for Safe Medication Practices (ISMP) Medication Safety Alert newsletter item noted an example of such an error that occurred after a patient transferred to another unit.¹
Before transferring the patient, a nurse removed all the patient’s morning medications from the automated dispensing cabinet (ADC) and administered them to the patient. Because it was still early in the morning, the nurse on the receiving unit gave the patient the same medications, without first checking the patient’s medication administration record (MAR).
ASHP Weighs In
As an error such as this can have serious implications, organizations have stepped in to help reduce them. In Medication Misadventures, ASHP offers guidelines for processes to prevent medication errors in hospitals, including:
- Ensuring sufficient personnel to perform tasks
- Creating an ongoing systemic program of quality improvement and peer review
- Tasking pharmacy with procurement, distribution and control of all drugs
- Avoiding use of patient’s own/home medications
They also offer recommendations for prescribers, nurses, patients/caregivers and pharmaceutical manufacturers and approval organizations, since this is a pervasive issue that spans every area that comes in contact with drug distribution.
Minimize Errors with ADCs
To minimize errors, hospitals can choose to use ADCs equipped with safety features, such as these offered by Omnicell:
- Last Issue Alert² – a hospital-wide alert–which is recommended by ISMP– that warns nurses when removing a medication previously issued for a patient within a set time period, regardless of the cabinet being used. The last issue date and time will be displayed in red, drawing the nurse’s eye to this critical information.
- Scheduled Meds – a tab that displays the list of medication orders that are within the administration due time, including the early/late window. Once an ordered medication is issued from the cabinet within this time period, it is no longer displayed on the Scheduled Meds list.
- Last Issue Status – a display shown during the medication selection process that presents the last date and time the medication was issued, the cabinet from which it was taken and who removed it
Reducing Risk to Improve Patient Safety
Greater opportunity for error occurs when care is transferred between nurses, when a patient transfers to a different level of care, or during nurse shift changes. The risk can increase when the patient profile is not available.
By implementing effective processes and the proper equipment, hospitals can minimize these errors, thus providing safer and higher quality care for its patients.
1 ISMP Medication Safety Alert newsletter, September 5, 2013.
2 Feature available with Omnicell software version 16.0 and above.