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Scan, Scan, Give - NEW
"At our hospital, we initialized a Scan, Scan, Give method when it came
to passing medications. That is scan the patient, scan the medication, and
then give the medication. We teach that to all our incoming nurses and keep
reminding the staff of this method when passing meds. It may not seem like a
huge leap, but it has really worked for us so that the 5 rights are
observed."
No Ticket, No Drug
"Do not release any medication to anyone at the hospital window if they come
without any paperwork. We have several departments that use "odd ball"
products. When we process the order we put them by the window to pick up.
The staff come down with very little information other than "Q-Pump" or "X"
solution. Since it is the only one there on two occasions it was dispensed.
On both of these occasions we had an other dept with an odd ball and the
solution was brought to the wrong department other than what was stated on
the pharmacy label. No ticket no drug is our policy."
Double Check in Retail
"In the retail pharmacy I previously worked for, we implemented a new policy
of double-checking medications and patient names upon pick-up. We had been
seeing some errors with patients receiving medications meant for other
patients. We began asking the customer to spell their name and verify their
address. We also started matching bottles to labels to ensure we had the
correct number of prescriptions for that patient."
Narcotic Bowel
"We quickly review the last 24 hours for narcotic usages and pharmacy
prescribes a stimulant/softener bowel program for all patients on scheduled
narcotics and those getting three or more PRN doses per 24 hours. We have
nearly eliminated our Fleets enema use and intestinal blockages from
narcotic bowel."
Highlighting Orders
"For all medication orders, I highlight all orders with a colored
highlighter after I have finished entering the complete order into the
pharmacy system. If I have questions about an order, I mark them with a
different color, and once clarified, will then enter the order into the
pharmacy system and then highlight the order. This ensures that all orders
are entered on the patient's profile and keeps track of pharmacy
interventions. (Note: We use handwritten orders that are faxed by nursing to
pharmacy for order-entry.)"
Just Ask
"Implemented the ASHP Just Ask program to encourage hospital patients to
just ask their hospital pharmacists questions about their medications."
PRN Prescriptions
"We created PRN prescription reminders where M.D.s are sent a reminder to
specify max dose/24 hours or frequency of administration of PRN medications
before PRN prescriptions could be processed in Long Term Care facilities."
DOB
"Always ask for a date of birth. It is the only tool to be able to
differentiate when picking up medications and your label has that
information."
Dispensing Processing Errors
"Keeping track of undispensed 'processing errors' that are caught before
dispensing can help in many ways. Obviously it prevents a dispensed error.
Secondly, it eventually allows a retrospective look at the dispensing
process to provide an opportunity for improvement at troublesome production
points. Even though these troublesome points might usually get 'caught', a
high volume glitch, will often eventually result in an error. Thirdly,
developing a list of common production defects is a great
pharmacy-process-specific tool to use as a checklist when checking for the
accuracy of the whole dispensing process at one or more quality
check-points."
Spreading the Word
"I am pharmacist in a non-traditional setting as a medical writer. I have
done my part in education by assisting colleagues in the development of CE
programs on medical errors. Additionally, I educate health care
practitioners on things they can do to prevent medication errors. I have
also report information on medication mix-ups and errors within some of my
publications and am planning on writing an article on medication error
prevention for hospitalists."
Pre-made IVs
"In the main pharmacy we had two different pre-made IV bags that came in frozen
from the same manufacturer. The bags looked nearly identical. We would defrost large
quantities of these bags at a time in two separate bins in the refrigerator. These
were later to be delivered to Pyxis stations at the various nursing stations. When
we took the bags out of the freezer and moved them to the refrigerator, we had bright
neon stickers that were printed with the drug name. One was pink and the other was
green. These stickers were placed on the bags before they were put into the bins
in the refrigerator. This helped us eliminate mistakes before they could happen,
such as the wrong bags being brought to and stocked in the Pyxis machines. We found
this simple system to be effective."
Chemo Concentrations
"I was starting to compound a STAT Pediatric Chemo prescription (Cytarabine)
when I noticed the concentration on the vial did not match the one listed on the
order. The concentration on the vial was twice as much as the one listed on the
order! I immediately brought this to the attention of the staff that was in the
pharmacy outside of the cleanroom. It turned out that the new concentration had
been ordered and placed on the shelf in the same location as the old concentration.
I was so glad I caught it before compounding and before it got administered! It
could of easily resulted in a patient death, considering the age of the patient
and the type of medication that was involved.
From that point on, we labeled all of our hazardous medications on the shelf with
a fluorescent green sticker. Additionally, when the technician picked an order they
were required to physically write down the concentration as verification that they
match. In order to prevent the same mistake from happening again, we changed our
process."
Pyxis Alerts
"We marked specific Pyxis pockets to warn nursing staff of any high alert concentrations/doses.
Staff would have to select the medication from the Pyxis list before having access
to the medication, however some doses or concentrations can appear similar to
each other. So if they selected one of these, there was an alert for them to double-check the
concentration/dose before pulling the med out of the Pyxis."
Depakote Mixups
"When I was in long term care we had a very large patient base that was on
Depakote. Depakote and Depakote ER look the same and are very easy to confuse. We
ended up putting the color of the tablet behind the drug name - Depakote ER 500
mg (Gray), Depakote 500 mg (Pink). This provided a very quick second check to ensure
that the extended release tablet had been picked. This reduced our Depakote medication
error down to almost nothing."
