The management of medications as an important part of patient care is essential to support safe patient care. Incorrect dosing, wrong patient administration, and unsafe storage/preparation practices can lead to patient harm, even death. To eliminate any potential harm that could be caused by medications, healthcare organizations develop and implement effective medication management practices with a focus on safety. Despite these efforts, we still observe opportunities with organizations that may lead to patient harm. Here are some examples of our observations, discovered during mock surveys, that may help you identify opportunities in your medication management practices.
Look Alike/Sound Alike Medication (LASA):
It is imperative that staff administering medications are cognizant of those agents that may look alike or sound alike with other medications. The Institute for Safe Medication Practice (ISMP) has published a listing of these medications in partnership with the US Food and Drug Administration. You can find the current list here: FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters Organizations must ensure that medications on their formulary that closely look alike or sound alike are identified and staff are educated to these risks. We have noted that organizations are not routinely maintaining current LASA lists. The Joint Commission standards require the list to be reviewed and updated annually. These lists are also not routinely available to staff in areas where medication preparation is being conducted. Additionally, organizations that label these medications as LASA agents are not consistent in their labeling practice.
High Alert Medications:
Staff should also be aware of those medications, that when used in error, may cause devastating effects on patients. These medications should prompt greater safeguards in practice to eliminate patient harm. The ISMP’s current list of medications that fall into this category can be found here: ISMP List of High-Alert Medications in Acute Care Settings. We are observing organizations that are not maintaining their current list of high alert medications or following their policies to ensure safe administration, such as not conducting a two person verification for insulin.
Safe handling of medications that have been identified as potentially harmful to staff is essential to ensure their safety. The National Institute for Occupational Safety and Health (NIOSH) maintains a current listing of these medications include exposure risks and safe handling guidance at this link: NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016 We have observed where staff do not have access to a current list, have not been trained to its use, and the lack of available safeguards such as respiratory protection, gloves and spill kits.
Staff must use aseptic technique in the preparation of medications to avoid contamination from infectious sources and potential medication sensitivities from residue. We have observed medication preparation on work surfaces without staff first disinfecting the area. These include in the pharmacy and on the patient care units. We have found pill splitters, pill cutters, and counters with visible pill residue. Medication areas and rooms are often found with dust and debris build up, especially on high surfaces and under dispensing devices.
Safe storage practices ensure that medications are safe from infection and maintain their potency. We have observed vials of single use medications labeled and timed for reuse (often due to staff not recognizing that the vial is single use). We have found intravenous fluid containers out of their overwraps without indication of the beyond use date (these are based on the manufacturer). Additionally, crash/procedure cart medications have been found expired. Our observations have included medications stored outside of their manufacturer’s temperature range. These include medications stored in refrigerators and warmers. Ensure you check the manufacturer’s instructions for use for guidance on storage parameters.
Maintaining secure storage of medication ensures that unauthorized individuals cannot access medications and that medications are available for patient use. We continue to find unlocked cabinets containing medications, medication dispensing systems with unlocked drawers, and unsecured pharmaceutical waste of controlled medications.
The management of pain with pharmaceutical interventions has been a frequent focus for survey teams. Our observations continue to find opportunity with documentation of the assessment and re-assessment of pain after administration of analgesia where there is misalignment with policy expectations. Organizations are also not documenting the circumstances when a patient requests a lower dose/lesser potent medication for a higher level of reported pain.
Safe administration of titratable medications will be a focus for survey teams. Our observations are medications not being titrated per the provider order. Often these are vasopressor medications titrated at higher dosages. Staff should ensure to notify the provider if a patient is not responding to the titration order. They may need to alter the order to ensure the patient condition stabilizes. Nurses who titrate medications outside of the provider order are potentially operating outside of their scope of practice. Organizations should review their medication titration practices ensuring that nurses and providers are supported in titrating medications that is both safe and timely to the patient’s needs.
Although the advent of Computer Provider Order Entry (CPOE) was thought to decrease duplicative medication orders, several organizations have continued to observe them, even with some experiencing increased occurances. We are continuing to observe several duplicative therapeutic entries, especially with analgesics. The most common culprit is conflicting orders for Acetaminophen, where one order is for pain and the other is for pain/fever – both with differences in dosage and frequency.
Discharge Medication Orders:
It is important that patients are provided clear discharge orders to ensure continued safe care. Our observations are that organizations with built in discharge instructions in their Electronic Medical Record are not completing the discharge medication sections with clear instructions on the medication, strength, frequency and when the last dose occurred and/or when the next dose would be due.
Safe use of sample medications includes safe storage, distribution, and management. We are observing opportunities where organizations do not have a process in place to identify patients who may have received sample medications that are under recall.
The use of medications or solutions in the Operating Room or during clinical procedures often requires preparing injectable medications. Our most common observation is the failure to properly label the medications or solutions. To ensure safe administration, staff must label these medications or solutions with the:
- Medication or solution name
- Amount of medication or solution containing medication (if not apparent from the container)
- Diluent name and volume (if not apparent from the container)
- Expiration date when not used within 24 hours
- Expiration time when expiration occurs in less than 24 hours
Event reporting and mitigation:
If actual medication error events or near misses occur, it is imperative that these are reported and reviewed by organizations to determine root cause and contributing factors to prevent future events. Our observations have been that organizations do not have a robust review process and sharing of findings. Often discussed during the Data Management sessions, organizations are not able to speak to their findings of these occurrences and mitigating actions taken to prevent them. Additionally, organizations often struggle to describe their follow-on observations after implementing any prevention actions.
Organizations with effective medication management programs approach their challenges from a multi-disciplinary perspective. The process of ordering, dosing, storing, preparing, administering, and monitoring medications requires all members of the healthcare team. It is essential that organizations review their practices for opportunities, as indicated above, to reinforce or retool their programs to align with regulatory requirements.
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