The Best Error-prevention Tools for the Job

Despite error-prevention efforts,confusing drug names and lookalikepackaging continue to becommon sources of medication errors.Selecting the best error-preventionstrategies is not an easy task. Even whensystem-based causes have been identified,it may be unclear which error-preventionstrategies will be most effective.

Listed below are examples of error-preventionstrategies in order of effectivenessfor creating lasting systemchanges for safe medication use. Thoselisted first are more powerful becausethey focus on changes to the system inwhich individuals operate. As the listdescends, strategies that target systemchanges but rely in some part on humanvigilance and memory are presented.

Fail-safes and constraints are amongthe most powerful and effective error-preventionstrategies. They involve truesystem changes in the design of productsor how individuals interact within the system.Examples outside of health careinclude the inability to start a car whilethe gearshift is in reverse or using fingerprintverification to enter a building orcomputer system. At a community pharmacywhere the pharmacy is integratedwith the cash register, a fail-safe wouldprevent the clerk from ringing up the prescriptionunless final verification by apharmacist was noted in the system.

Forcing functions are procedures thatcreate a "hard stop" during a process tohelp ensure that important information isprovided before proceeding—oftenreferred to as a "lock and key" design.Examples include a pharmacy computersystem that prevents overriding selectedhigh-alert messages without a notation(eg, entry of the patient-specific indicationfor selected error-prone medications), or abar-code scanning system that does notallow final verification of a product withouta positive match between the selectedproduct and the profiled medication.

Automation and computerization ofmedication-use processes and tasks canlimit reliance on memory. Examplesinclude pharmacy computer systemsthat can receive prescriptions sent electronicallyfrom a prescriber's handhelddevice or computer and thus eliminatetranscriptions and misinterpretations;robotic prescription preparation and dispensingtechnology; and computer systemsthat provide accurate warningsrelated to allergies, significant drug interactions,and excessive doses.

Standardization creates a uniformmodel to adhere to when performing variousfunctions, and it tends to reduce thecomplexity and variation of a specificprocess. For example, standardizedprocesses could be created to guide thepharmacist's final verification of a medication.On its own, standardization relies onhuman vigilance to ensure that a processis followed; therefore, it is less effectivethan the strategies mentioned previously.

Redundancies incorporate duplicatesteps or add another individual to aprocess to force additional checks in thesystem. Involving 2 individuals in aprocess reduces the likelihood that bothwill make the same error with the samemedication for the same patient. Thepotential for error still exists, however,because the redundant step may beomitted or ignored. Examples of redundanciesinclude the use of both brandand generic names when communicatingmedication information or requiringindependent double-checks of high-alertmedications before dispensing. Patientcounseling is often an underutilizedredundancy that can detect many errors.

Reminders and checklists help makeimportant information readily available.Examples include using auxiliary labels todistinguish products; building look-andsound-alike alerts into order-entry systems;and using preprinted prescriptionblanks that include prompts for importantinformation (eg, medication indication,allergies, patient birth date).

Rules and policies are necessary inorganizations. Effective rules and policiesguide staff toward an intended positiveoutcome. Some may add unnecessarycomplexity and may be met with resistance,however, even rightfully so, especiallywhen implemented in response toan error. Because their use relies onmemory, they should be used as a foundationto support more effective strategiesthat target system issues.

Education and information areimportant tactics when combined withother strategies that strengthen themedication-use system. The effectivenessof these tactics relies on an individual'sability to remember what has beenpresented. Thus, on their own, they offerlittle leverage to prevent errors.

When implementing error-preventionstrategies in your organization, each ofthese examples is important to consider.While strategies at the bottom of the listmay be used initially, we must realize thatthey will not be effective for long-lastingerror prevention when used alone. In orderto do a better job at preventing medicationerrors, we need to employ a variety ofstrategies that focus on system andhuman factor issues. Because people cannotbe expected to compensate for weaksystems, routinely evaluate the error-preventionstrategies being used in yourorganization. Consider whether more powerfulstrategies exist that could be implementedto enhance medication safety.

Dr. Gaunt is a medication safetyanalyst and the editor of ISMPMedication Safety Alert!Community/Ambulatory Care Edition.