Preventing Medication Errors

Center for Drug Evaluation and Research. (2019, August 23). Working to reduce medication errors. U.S. Food and Drug Administration. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors#:~:text=A%20medication%20error%20is%20defined,Medication%20Error%20Reporting%20and%20Prevention.

This article defines what a medication error is and lists examples of the harmful results these errors can cause.  It also provides examples of how to reduce medication errors.  This resource is valuable in laying the basic groundwork to understanding medication errors and their consequences.

Najafpour, Z., Arab, M., Biparva, S., Yaseri, M., Hatamizadeh, M., Goudarzi, Z., Bahramnezhad, F., & Shayanfard, K. (2008). Error reporting and disclosure. https://doi.org/10.21203/rs.3.rs-16635/v1

This article stresses the importance of reporting medication errors.  It touches on under-reporting and disclosure to the patient/family.  It also includes barriers (real or perceived) that may prevent a nurse from reporting an error.  This resource is useful in encouraging medication error reporting for patient safety.

Sessions, L. C., Nemeth, L. S., Catchpole, K., & Kelechi, T. J. (2019). Nurses’ perceptions of high-alert medication administration safety: A qualitative descriptive study. Journal of Advanced Nursing, 75(12), 3654–3667. https://doi.org/10.1111/jan.14173

This study of high-alert medications centers around the interviews of 18 nurses.  The article includes the interview guide for reference.  This study highlights the common root cause(s) of medication errors and how to prevent them.

The Joint Commission. (2018). National Patient Safety Goal for anticoagulant therapy (R3 Report, Issue 19, Dec. 7, 2018). https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_19_anticoagulant_therapy_rev_final1.pdf?db=web&hash=7C6FA69A5DF9294B7BADF2B52C653FCA&hash=7C6FA69A5DF9294B7BADF2B52C653FCA

This article outlines the requirements of the Joint Commission regarding reducing the likelihood of patient harm associated with the use of anticoagulant therapy. This resource is valuable as it clearly outlines the standards that must me met to safely administer anticoagulants such as heparin.

World Health Organization. (2019). Medication safety in high-risk situations [PDF]. https://apps.who.int/iris/bitstream/handle/10665/325131/WHO-UHC-SDS-2019.10-eng.pdf

This report details medication safety in high-risk situations.  This report is valuable as it provides examples of medication factors, provider and patient factors, and environmental factors that could contribute to safety issues.  It also includes a list of high-risk, high-alert medications.