BOX 5-2

Improving Medication Safety: Actions for Individual Pharmacists

  • Monitor the medication safety literature and other resources regularly for information related to medication errors, and take action to ensure that similar errors will be avoided in the local practice setting. (Amb and Hosp)

  • Develop, implement, and follow a medication error avoidance plan. (Amb)

  • As part of this plan, establish a routine procedure for double-checking filled prescriptions waiting to be picked up and verifying the accurate entry of data on new prescriptions into computer systems. (Amb)

  • Monitor error frequencies, and correct system problems associated with errors. (Amb and Hosp)

  • Use the show-and-tell counseling method to detect and correct dispensing errors; this should include verification of patient identity. (Amb)

  • Educate consumers regarding error prevention techniques and resources (e.g., websites such as http://www.ismp.org, http://www.safemedication.com, and http://www.ahrq.gov). (Amb)

  • Pharmacy managers designate a medication safety officer with responsibility for improving the safety of prescription filling processes. (Amb)

  • Advocate for a medication safety officer with responsibility for improving medication safety throughout the hospital. (Hosp)

  • Create a safe work environment by optimizing lighting levels, using a magnifying lens or resizable scanned prescription for viewing prescription slips, minimizing distractions, and arranging drug storage areas to call attention to drugs with a high potential for errors leading to patient harm. (Amb)

  • Create a safe work environment by optimizing lighting levels and minimizing distractions and interruptions. (Hosp)

  • Advocate for a statewide medication safety coalition, to include the state board of pharmacy, pharmacy organizations, practitioners, and consumers. (Amb and Hosp)

  • Report errors and near misses to both internal and external medication error reporting programs or systems to help others learn how to avoid similar problems. (Amb and Hosp)

  • Request resources needed to promote accurate prescription dispensing (clinical decision support, bar code verification technology, time for counseling patients). (Amb)

  • Be assertive in requesting resources needed to promote accurate medication processing and dispensing (clinical decision support, bar code verification technology). (Hosp)

  • Actively pursue a tiered system of clinical alerts that can facilitate better response to serious medication safety issues (e.g., suppress trivial warnings and retain those with a high probability of patient risk). (Amb and Hosp)

  • Evaluate and continuously monitor new technologies (e.g., automated prescription filling machines) regarding the risk of introducing medication errors. (Amb)

  • Evaluate and continuously monitor new technologies (e.g., infusion pumps, automated medication dispensing machines) regarding the risk of introducing medication errors. (Hosp)



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