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National Coordinating Council Announces Medication Administration Recommendations To Prevent Errors September 16, 1999 Rockville, MD — At its recent meeting, The National Coordinating Council for Medication Error Reporting and Prevention (Council) identified a set of recommendations to help reduce the risk of harm to patients through errors in administering medications. The Council is devoted primarily to reducing medication errors in the health care system. The recommendations are geared toward safer administration of medications in all areas of health care delivery. The Council is particularly concerned that health care professionals who administer medications be equipped with the proper pharmacological, product, and therapeutic information to best manage patients’ drug therapy regimens, as indicated by the following recommendation. The Council recommends that 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 medications as well as precautions and contraindications; expected outcomes from their uses; potential adverse reactions and interactions with food or other medications; actions to take when adverse reactions or interactions occur; and, storage requirements. In addition, the Council underscores the importance of paying close attention to product labels prior to administering medications with the next recommendation. The Council recommends: that health care professionals administer only medications that are properly labeled; 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. The United States Food and Drug Administration has received 6,000 medication error reports since 1992, of which 50% were related to confusion in the labeling or packaging of the product. "Many of these errors could have been avoided had the medications been triple checked," said Deborah Nadzam, PhD, RN, FAAN, chair of the Council. The Council recognizes the need for patient follow up in order to detect adverse consequences. Th following recommendation emphasizes the Council’s desire for health care professionals to care for patients in the post-administration phases of drug therapy and to be prepared for the possibility of adverse drug reactions and interactions. The Council recommends continuous patient monitoring for desired and/or unexpected medication effects. The problems associated with medication errors in the United States are widespread. As a result, the Council is committed to reducing and ultimately preventing medication errors. Medication errors may lead to adverse drug events (ADEs). ADEs, defined as "injury resulting from medical intervention related to a drug," significantly diminish the quality of care and dramatically increase health care costs. A 1998 Journal of the American Medical Association study estimated that 106,000 hospital patients die and 2.2 million are injured each year by adverse reactions to medications. A Harvard Medical Practice study surveyed 30,000 hospitalizations in several New York hospitals. The results demonstrated that 3.7% of the patients experienced serious, disabling ADEs during their hospitalizations. The majority of these (19%) were due to medication errors. The recommended administration guidelines (attached) are aimed at reducing such costly medication errors, which are financially costly to hospitals, but more importantly, can be both economically and emotionally devastating to patients and their families. © 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.