Medication Error

Abstract

Medication error is one of the leading patient safety concerns in healthcare, causing morbidity and mortality. It can occur at all stages of the medication process. Medication errors are frequent, often harmful, but with good systems and processes are largely preventable. There are five essential strategies to improve medication safety and avert errors. These include: (1) Appropriate usage of information technology (electronic health records (EHR), computerized physician order entry (CPOE), point-of-care clinical decision support (CDS), and bedside bar-coded medication administration (BCMA). (2) Addressing health literacy and engaging patients and families. (3) Standardize protocols, dosing, order sets with alerts, assessment parameters, and early recognition of potential adverse events for high-alert medications. (4) Thorough medication reconciliation at points in transition of care where new medications are ordered or existing orders are rewritten. (5) Foster pharmacy collaboration and better communication and interaction among members of the healthcare team and the patient. Every discipline is responsible to stop the line at any interval of the medication process when an error or potential error is identified. The goal is to prevent the error from reaching the patient. An organizational culture of safety is critical, where communication is embraced and staff are empowered to report concerns so changes can be made to prevent errors and improve safety.