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Recommendations for Improving Medication Safety by Reducing Inappropriate Polypharmacy

The term “polypharmacy” first appeared in the literature in the 1800’s and was used to describe the use of multiple medications to treat a single condition. Since then, “polypharmacy” has been used to refer to many situations, including getting medications from more than one pharmacy and using more than one medication to treat a single condition. However, the most commonly used definition refers to a situation where a patient is being treated with many—five or more—medications.1,2

Recommendations to Weigh Patients and Document Metric Weights to Ensure Accurate Medication Dosing (adopted October 25, 2018)

Accurate patient information (e.g., age, allergies, laboratory results) helps practitioners select appropriate medications, doses, and routes of administration.1 One vital piece of patient information, the patient’s weight, is especially important because it is used to calculate the appropriate dose of a medication (e.g., mg/kg, mcg/ kg, mg/m2). A prescribed or dispensed medication dose can differ significantly from the appropriate dose because of a missing or inaccurate patient weight.

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.

Recommendation for Manufacturers, Regulators, and Standards Setters to Promote the Safe Use of Modifiers in Prescription Drug Proprietary (Brand) Names

These recommendations apply to manufacturers and regulators involved in the production of medication.
 

Numerous medication errors associated with the use of modifiers in drug proprietary names have been reported through various reporting programs including the Food and Drug Administration (FDA) MedWatch Reporting Program and the ISMP National Medication Errors Reporting Program (ISMP MERP). 
 

Factors that contribute to medication errors associated with the use of modifiers in drug proprietary names include:

Statement Advocating for the Elimination of Prescription Time Guarantees in Community Pharmacy

Statement

The National Coordinating Council for Medication Error Reporting and Prevention advocates the elimination of prescription time guarantees and a strengthened focus on the clinical, accuracy and safety activities of pharmacists within all pharmacy practice settings especially the community pharmacy setting.

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