ASHP guidelines on preventing medication errors in hospitals.

The goal of drug therapy is the achievement of defined therapeutic outcomes that improve a patient’s quality of life while minimizing patient risk. There are inherent risks, both known and unknown, associated with the therapeutic use of drugs (prescription and nonprescription) and drug administration devices. The incidents or hazards that result from such risk have been defined as drug misadventuring, which includes both adverse drug reactions (ADRs) and medication errors. This document addresses medication errors—episodes in drug misadventuring that should be preventable through effective systems controls involving pharmacists, physicians and other prescribers, nurses, risk management personnel, legal counsel, administrators, patients, and others in the organizational setting, as well as regulatory agencies and the pharmaceutical industry. This document suggests medication error prevention approaches that should be considered in the development of organizational systems and discusses methods of managing medication errors once they have occurred. These guidelines are primarily intended to apply to the inpatient hospital setting because of the special collaborative processes established in the setting [e.g., formulary system, pharmacy and therapeutics (P&T) committee, and opportunity for increased interaction among health-care providers]. Recommendations for practice settings other than hospitals are beyond the scope of this document, although many of the ideas and principles may be applicable. Medication errors compromise patient confidence in the health-care system and increase health-care costs. The problems and sources of medication errors are multidisciplinary and multifactorial. Errors occur from lack of knowledge, substandard performance and mental lapses, or defects or failures in systems. Medication errors may be committed by both experienced and inexperienced staff, including pharmacists, physicians, nurses, supportive personnel (e.g., pharmacy technicians), students, clerical staff (e.g., ward clerks), administrators, pharmaceutical manufacturers, patients and their caregivers, and others. The incidence of medication errors is indeterminate; valid comparisons of different studies on medication errors are extremely difficult because of differences in variables, measurements, populations, and methods. Many medication errors are probably undetected. The outcome(s) or clinical significance of many medication errors may be minimal, with few or no consequences that adversely affect a patient. Tragically, however, some medication errors result in serious patient morbidity or mortality. Thus, medication errors must not be taken lightly, and effective systems for ordering, dispensing, and administering medications should be established with safeguards to prevent the occurrence of errors. These systems should involve adequately trained and supervised personnel, adequate communications, reasonable workloads, effective drug handling systems, multiple procedural and final product checks by separate individuals, quality management, and adequate facilities, equipment, and supplies. The pharmacist’s mission is to help ensure that patients make the best use of medications. This applies to all drugs used by inpatients or ambulatory patients, including oral or injectable products, radiopharmaceuticals, radiopaque contrast media, anesthetic gases, blood-fraction drugs, dialysis fluids, respiratory therapy agents, investigational drugs, drug samples, drugs brought into the hospital setting by patients, and other chemical or biological substances administered to patients to evoke a pharmacological response. Through a systems-oriented approach, the pharmacist should lead collaborative, multidisciplinary efforts to prevent, detect, and resolve drug-related problems that can result in patient harm. An understanding of the risk factors associated with medication errors should enable improved monitoring of patients and medications associated with increased risk for serious errors and should enable the development of organizational systems designed to minimize risk. The pharmacist should participate in appropriate organizational committees and work with physicians, nurses, administrators, and others to examine and improve systems to ensure that medication processes are safe.