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Recommendations to Enhance Accuracy of Administration of Medications Adopted June 29, 1999 Revised June 2, 2005 Personnel to whom this applies: Nursing staff involved in administration of medications; other personnel involved in administration of medications (e.g., respiratory therapists, non-licensed personnel who are delegated tasks by a licensed professional, etc); Pharmacy staff; Health care administrators/managers. Technology plays an important role in the delivery of healthcare. Utilize technology, as appropriate, but evaluate its effectiveness on an ongoing basis. While technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors. The Council recommends: ...any order that is incomplete, illegible, or of any other concern be clarified prior to administration using an established process for resolving questions. ...as one aspect of the overall medication use system, the following checks be performed immediately prior to medication administration: the right medication, in the right dose, to the right person, by the right route using the right dosage form, at the right time, with the right documentation. ...organizations/companies provide employees with adequate training regarding medication administration devices and routinely monitor or verify that users of such devices demonstrate competency regarding the device, its operation, and its limitations. ...when electronic infusion control devices are employed, only those that prevent free-flow upon removal of the administration set should be used. ...the use of integrated automated systems (e.g., direct order entry, computerized medication administration record, bar coding) to facilitate review of prescriptions, increase the accuracy of administration, and reduce transcription errors. ...all persons who administer medications have adequate and/or appropriate access to patient information, as close to the point of use as possible, including medical history, known allergies, diagnoses, list of current medications, and treatment plan, to assess the appropriateness of administering the medication. ...all persons who administer medications have easily accessible product information as close to the point of use as possible, and are knowledgeable about: indications for use of the medication as well as precautions and contraindications; the expected outcome from its use; potential adverse reactions and interactions with food or other medication; actions to take when adverse reactions or interactions occur; and storage requirements. ...health care professionals administer only medications that are properly labeled and that during the administration process, labels be read three times: when reaching for or preparing the medication, immediately prior to administering the medication, and when discarding the container or replacing it into its storage location. ...at the time of administration, the name, purpose and effects of the medication be discussed with the patient and/or caregiver, especially upon first time administration and reviewed upon subsequent administrations. ...ongoing patient monitoring for therapeutic and/or adverse medication effects. ...the role of the work environment be considered when assessing safety of the drug administration process. Factors such as lighting, temperature control, noise-level, occurrence of distractions (e.g., telephone and personal interruptions, performance of unrelated tasks, etc.) should be examined. Sufficient staffing and other resources must be provided for the given workload. The science of ergonomics should be employed in the design of safe systems. ...data be collected and analyzed regarding the actual and potential errors of administration for the purpose of continuous quality improvement. ...both initial and ongoing training of staff, including licensed staff, support staff or non-licensed staff, and relief staff on accepted standards of practice related to accurate medication administration with the ultimate goal of medication error reduction. ...every organization establish policies and procedures for the medication administration process. This will ensure that all personnel, including licensed staff, support staff or non-licensed staff, and relief staff are informed of expectations related to the medication administration process. (See also the Council's Recommendations to Reduce Medication Errors in Non-Health Care Settings pertaining to the storage and administration of medications in a variety of non-health care settings.) © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. All Rights Reserved. *Permission is hereby granted to reproduce information contained herein provided that such reproduction shall not modify the text and shall include the copyright notice appearing on the pages from which it was copied.