Recommendations to Enhance Accuracy of Administration of Medications

Personnel to whom this applies: 1) nursing staff involved in administration of medications; 2) prescribers and other personnel involved in administration of medications (e.g., respiratory therapists, non-licensed personnel who are delegated tasks by a licensed professional, and others); 3) pharmacy staff; and 4) healthcare administrators/managers.

Technology plays an important role in the delivery of healthcare. Use technology, as appropriate, but evaluate its effectiveness on an ongoing basis. Although technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors.

The Council recommends the following:

  1. Any order that is incomplete, illegible, or poses any concern should be clarified before preparation and administration by using an established process for resolving and documenting issues.
  2. The use of patient-safety technology to enhance the safety of medication administration—such as electronic medication administration records (eMAR), bar coded medication administration (BCMA), automated dispense cabinets, and smart pumps—is encouraged when appropriate. 
    1. Although technology can reduce medication errors and enhance patient safety, it also has the potential to cause new types of unintentional errors.
    2. Monitor technology use and its impact that may lead to medication errors (e.g., override rates, adherence rates, etc.) 
    3. Use technology, as appropriate, but proactively evaluate its effectiveness and potential for workarounds on an ongoing basis.
    4. When infusion pumps are used, only use those that offer “free-flow” protection upon removal of the administration set should be used.
  3. The safety of all technologies and devices used within the medication administration system should be continuously monitored and evaluated according to any risk identified in published data, within the organization and/or across the healthcare continuum.
  4. Organizations should work towards integrated automated systems (e.g. electronic medication administration record, smart infusion pumps, bar coding) that can be used to increase the safety of administration errors (e.g., integration of smart infusion pumps with electronic health records)
  5. As one aspect of the overall medication use system, the following goals of the medication administration process should be included in the organizations processes and policies to ensure that systems are appropriately designed and functional for humans to safely administer medications: 
    1. the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason. (NOTE: Right is best defined as correct)
    2. Healthcare organizations should also ensure the medication administration processes are designed so that these goals can be achieved without the use of workarounds and/or shortcuts, or unintended consequences. 
  6. Organizations/companies should ensure that all appropriate staff, including temporary and contracted staff, receive adequate training regarding safe medication practices and technologies used during the administration process (e.g., eMARs, BCMA, ADCs).
  7. Conduct both initial and ongoing training of staff—including licensed staff, medical students and residents, support/non-licensed staff, temporary and per diem staff, and relief staff, whether contracted or employed—on accepted standards of practice related to safe and accurate medication administration with the ultimate goal of preventing or detecting medication errors, and verify competencies prior to their administration of medications.
  8. All persons who administer medications must have adequate and appropriate access to patient information—which includes medical history, known allergies, patient weight, diagnoses, list of current medications, laboratory data and treatment plan—as close to the point of use as possible to assess the appropriateness of administering the medication and help to meet the goals of the medication administration process.
  9. All persons who administer medications should have easily accessible policy, procedure and product information (e.g., organizational protocols, guidelines, drug references) as close to the point of use as possible and are knowledgeable about the following:
    1. Indications for use of the medication as well as precautions and contraindications
    2. Access to brand and generic names of medications
    3. The expected outcome from its use 
    4. Patient specific dosing guidelines
    5. Drug preparation requirements 
    6. Storage requirements
    7. Potential adverse drug effects and interactions with food or other medications
    8. Actions to take when adverse drug effects or interactions occur
      1. Specific considerations for administration of medications, such as specialized infusion sets
  10. Healthcare professionals should only administer medications that are properly labeled, and labels should be read during the following steps in the administration process: 
    1. Reaching / Handling for the medication
    2. Preparing the medication
    3. Immediately before administering the medication
    4. Discarding the container or replacing unused medication it into its storage location
  11. Ongoing patient monitoring (e.g. direct observation, process monitoring) and follow-up should occur for the desired therapeutic effect(s) and for potential adverse drug effects, in accordance with the organization’s policies and procedures and generally accepted practices for medications. 
  12. The role of the work environment is considered when assessing safety of the drug administration process. 
    1. Factors such as lighting, temperature control, noise level, and potential for distractions (e.g., telephone and personal interruptions, performance of unrelated tasks, and others) should be examined. 
    2. Sufficient staffing and other resources must be provided for the given workload. 
    3. The science of ergonomics should be used in the design of safe systems (see USP–NF General Chapter <1066> Physical Environments that promote Safe Medication use).
  13. Data regarding the actual and potential errors (e.g. near misses, workarounds, overrides of technologies) of administration be routinely collected and analyzed for the purpose of continuous quality improvement.
  14. Every organization shall establish policies and procedures for the engagement of patients and family caregivers related to the medication administration process. 
    1. During medication administration, the name, purpose, and (intended) effects of the medication are discussed with the patient and/or caregiver. The information is reviewed upon subsequent administrations. 
    2. The personnel should assess the ability of the patient to understand the information being taught.
    3. The personnel can then teach patients and their families, using the teach back method) at the bedside about the medication administration procedure, the purpose of the medication, how the medication works, how to recognize possible adverse events, and what to do if an adverse event occurs.

(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.)

1 is external) Accessed August 2, 2014

Actions/Decisions are those of the Council as a whole and may not reflect the views/positions of individual member organizations.