• List the elements for inclusion in a complete verbal order,

• Verify the drug by spelling, use of brand and generic names, and/or the indication for use and

• Instructions should be provided without abbreviation (e.g. take three times a day, not TID)

It has been recommended that by 2010 all prescribers and pharmacies use electronic prescribing or e-prescribing. ^{6, 25} The goal of this system is to eliminate the legibility factor of prescriptions and allow for automated check of drug interactions, allergies, dosing and up-to-date drug information. Other technology, which may reduce medication errors in the hospital setting, includes computerized prescriber order entry and bar code medication administration.

According to the National Community of Pharmacists Association (NCPA) more than 90 percent of community pharmacies throughout the United States are able to receive electronic prescriptions. E-prescribing not only allows for reduction of error but also gives pharmacists more time to counsel patients. Although technology may not entirely eliminate errors from occurring, it does eliminate a portion of the human factor.

An additional goal is to allow prescribers to have full access of a patient’s medication history regardless of the pharmacy they use. This electronic medication record (EMR) would assist with issues regarding polypharmacy and potential drug interactions. E-prescribing and EMR software is available for prescribers, but unfortunately it is being underutilized. Pharmacy associations and governmental agencies need to educate prescribers on the benefits of technology and how they

can reduce and prevent medication errors.

Pharmacists

Pharmacists are in a key position to assure patient safety and minimize errors. All pharmacists should continually update themselves and their staffs on error-prone abbreviations and medications involved in errors. Pharmacists should be encouraged to utilize a checklist during the medication use process to ensure that all steps were followed from prescription drop off to patient pick-up. Tips to follow include verifying all patient information; accurate entry of the prescription; reading the drug label throughout the dispensing process (i.e., during drug selection from shelf, dispensing from the immediate container to new bottle, returning the drug to the shelf and placing the final product in the bag); always keeping the prescription, label and bottle together; checking expiration dates; and utilizing a double-check system (e.g., another individual or a computer system). ²⁹

Pharmacists should verify that all the drug information on the prescription is accurate. In the case of verbal orders, the pharmacist should immediately write down the order and read it back to the presciber prior to computer entry. Pharmacists need to educate their staff on error prevention by encouraging a nonpunitive environment, identifying their role in the prevention of errors and reviewing store policies and procedures.

The role of the work environment is a consideration in the human aspect of error. The NCC MERP recommends that such factors as lighting, noise, temperature, distractions, telephone and workload all be examined in

the workplace and discussed with supervisors and staff to implement change.

With respect to drug name confusion, ISMP recommends several steps that can be taken to minimize error at the pharmacist level: do not store problem or high-alert medications alphabetically by name, store those high-alert medications in a separate location, provide both brand and generic drug names for patients, ask for both brand and generic drug names on prescription orders from prescribers, ask for the purpose of the medication and provide the patient with information on their medications. ³⁰

Patient education and counseling is a key recommendation in the prevention of medication error because it is the final opportunity to review the patient’s regimen. The final step in the medication use process is medication administration by the patient or a caregiver. Pharmacists can make sure that patients know how to take their medication, what their medication is for, what side effects to expect, drug monitoring and potential risks of drug interactions with other prescription or nonprescription medications.

Patient

According to the IOM, it is also the responsibility of the patient to take charge and be involved with their health care and work with their provider and pharmacist to prevent error. Pharmacists should play an active role in encouraging patients to be knowledgeable about their medications and to ask questions when needed.

There are a number of steps a patient can take to minimize the potential for error. These include:

• Keeping a medication list and taking it along whenever visiting a provider,

• Knowing what each medication is for,

• Asking questions about his or her drug therapy,

• Asking for written material about his or her medication or condition,

• Making sure he or she can read the prescription before leaving the office,

• Checking the prescription bottle before he or she leaves the pharmacy and

• Knowing what each medication looks like, as well as their brand and generic names.

The pharmacist can help patients develop these habits. When the patient picks up his or her medication, the pharmacist or pharmacy technician should take a few moments to state the name of the medication, the dose and directions for administration. The patient also should be encouraged to call the pharmacy if he or she has any questions later on.

In the case of a pediatric patient, parents should follow the above steps, as well as make sure that they are given an appropriate measuring device if the medication is in a liquid formulation. Patient information resources related to medication safety are found in Table 9.

HEALTHCARE AGENCIES

NCC MERP recommends that the error reporting programs through the FDA, USP or ISMP be simple, uncomplicated and effortless. Error analysis using FMEA and RCA should be a standard part of error identification and evaluation. Agencies should continue to develop training programs pertaining to prevention of medication error for patients, healthcare professionals and manufacturers. This includes developing documents for standardized manufacturing labeling, standardized patient drug information leaflets, encouraging

prescribers and pharmacists to share error experiences and a national phone helpline, which offers access to drug information for patients.

CONCLUSION

The goals in the prevention of error are to reduce the number of errors, identify errors prior to reaching the patient and enhance patient safety. In order to achieve these goals and promote quality improvement, pharmacists, pharmacy staff, patients and practitioners need to report actual or potential medication errors. Error reporting can take place through the FDA Med Watch or the USP-ISMP Medication Errors Reporting Program. These reporting systems are voluntary and confidential. Without reporting events, there would be no information on how to change the system, determine how to prevent the event in the future or improve patient safety. Information sent to these agencies is ultimately fed back to the FDA and manufacturers to implement changes. According to the 2003 IOM report, Patient Safety: Achieving a New Standard for Care, all healthcare professionals need to be vigilant in identifying, documenting and reporting potential or actual errors and taking the appropriate steps to prevent error. Patient safety programs should be implemented to identify the failure of a system, for error analysis of the failure, and recommendations should be made to redesign the system based on that analysis. These programs should involve the pharmacist, prescriber and patient in order to reduce and prevent future error.

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