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May 25, 1999 Rockville, MD — At its recent meeting, the National Coordinating Council for Medication Error Reporting and Prevention (Council) identified a set of recommendations to dramatically reduce the potential for harmful errors to patients in dispensing medications. The Council is devoted primarily to reducing medication errors in health care delivery. The recommendations are aimed at safer dispensing of medications in all health care facilities. "Given today’s fast-paced health care environment, medication errors are more apt to occur unless there are mechanisms in place to reduce and prevent those errors from reaching patients," said Council chairman Deborah Nadzam, PhD, RN, FAAN. "It is the Council’s goal to make recommendations that all health care practitioners can adopt easily, so that patients can be protected." The Council reviewed the problems that can occur when medications are dispensed in a variety of settings, including hospitals, nursing homes, home health care, and retail pharmacies. "Some of the problems can be caused by environmental conditions, distractions, and workload," said Diane D. Cousins, R.Ph., Council secretary and vice president for USP practitioner and product experience. "Therefore, facilities should provide proper lighting, appropriate temperatures, and few distractions (e.g., noise, telephone calls, clutter) in the dispensing area to help reduce factors contributing to errors." "One of the most crucial recommendations relates to the ever-quickening pace of medication dispensing today; therefore, the Council emphasizes that the label be read at least three times before the medication reaches the patient," continued Nadzam. For example, the label would be read by the pharmacist 1) when the product is selected from the shelf; 2) when the product is being placed into the proper packaging for patient use; and, 3) when the product is returned to the shelf. Automated and independent checks by a second individual are also encouraged. The Council also recommends that pharmacists maintain up-to-date patient profiles to assist them in assessing the appropriateness of patient orders. Furthermore, counseling patients on the proper use of medications should be viewed as opportunities to educate patients and their caregivers, as well as to verify the accuracy of the dispensing function. Since a number of medication containers resemble one another on the pharmacy shelves of health care facilities, the Council suggests using visual discriminators, such as signs or markers. This is key to minimizing confusion between and among strengths, similar looking labels, and similar sounding names. The Council is promoting these recommendations to encourage their implementation throughout the health care industry. In addition, within the next few weeks, the Council will release another set of recommendations that will focus on how to reduce the frequency and severity of medication errors during the medication administration process. At its next meeting, scheduled for late June, the Council will develop mechanisms for comparing medication errors and determining rates of errors. In addition, it will review the utility of comparative analyses, benchmarking, and incremental improvement.
© 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. |