Study Set Content:
Aim to reduce delay in accessing medication, errors relating to handwriting or transcription and allow orders to be made at the point of case or off-site
(ePrescribing), also known as Computerized Physician Order Entry (CPOE).
Alerts against prescribing certain medication such warnings of interactions and other cautions -Standardization of drug charts/prescription
Decision Support Tools:
: Prescribing protocols and guidelines, use of drug calculators and iPad based prescribing application, prescribing at patient’s bedside only (prevent cases where drug chart is removed from pt bed then getting it mixed up/forgetting decision)
Other methods
clear systematic workflow to reduce confusion, fatigue, muddled process from point of receiving a prescription to handling it out and patient counselling.
Dispensing Workflow:
Space, lighting, clear signing, minimum noise/distraction levels, cushioned flooring, good temperature/ ventilation control, grey or cream colored dispensing bench
Working environment
Suitable computer/screen angle/height, shelves not very low or very high
Ergonomic issues
identify an area where delivered stock can be temporarily stored and checked off before being used.
Delivery of Stock:
: No cluttered and overstocked refrigerators/shelves, use of dividers between look-alike-sound-alike products, separate similar products, use of sloping pull-out drawers that enable stock to be seen, group products per route of administration, a to z sorting system, group certain products together such as antiinfective or hypoglycaemics
Storage of Medicines:
Separate clinical and dispensing accuracy checks
Assembling Medicine:
ideally carried out by two people, checking against a prescription and not the printed label
Double checking
up to 83% of dispensing errors can be discovered during
patient counseling
Regular short mental breaks:
Trained staff, use of barcode scanning
Training nurses on drug administration
Education and Development:
No unnecessary night time drug administration, 5 right rule (
right patient, right medicine, right dose, right route, and right time),
Pre-filled syringes (can’t be pre-filled if dependent on pt
weight/kidney function)
try to eliminate/reduce medication error
Medication Safety Thermometer
Measurement tool for improvement that focuses on medication reconciliation, allergy status, medication omission, and identifying harm from high risk medicines.
Medication Safety Thermometer
Follows a 3 step process to identify harm occurring from a medication error. Data are collected on one day each month and enable wards, teams and organizations to: Understand the (Blank) of medication error and harm
burden
Measure improvement
over time
Connect frontline teams to the issues of medication error and harm, enabling immediate improvements to
patient care
