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Radiology Daily
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Complex Process of Medication Orders Vulnerable to Errors

March 9, 2008
Written by: , Filed in: Practice Management
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A nonprofit organization called the Institute for Safe Medication Practices
provides objective information and good safety points about how to prevent
medication errors.

A list of 28 serious preventable medical errors, termed ‘never events,’ has
been defined by the National Quality Forum. One group of ‘never events’ is
contained under the heading of care management events. A few of the categories
under this heading are somewhat controversial.

However, the first category of care management events is fairly well
understood by most clinicians–patient death or serious disability associated
with medication errors. These errors involve wrong drug, wrong dose, wrong
patient, wrong time of administration, wrong rate, wrong preparation, or wrong
route of administration.

This is another portion of health care that has been repeatedly evaluated and
investigated, and it is probably the most complex portion of health care
delivery. The process requires that a medication order from a physician go to
a pharmacist, who must be able to read the order and then find the appropriate
medication, dose, strengths, etc. The pharmacist then must get the medication
to the nursing unit in a timely fashion. The nursing staff then must
administer the medication as the order specifies.

Therefore, legibility can be an issue with the handwritten prescription,
especially for items such as identifying the proper drug and dosage.
Computerized physician order entry can overcome some of the problems of
legibility, but it creates its own set of problems, such as clicking on the
wrong drug. There are technical issues with the technological cures for these
types of problems, so the health care team must be aware of the types of
problems involved with handwritten and computerized medication orders.

A nonprofit organization called the Institute for Safe Medication Practices
focuses on medication error prevention and safe medication use. They have an
enormous amount of expertise, and they also have a terrific website that
provides information about how to prevent medication errors, what other
clinicians have lived through, and what others have found in terms of
breakdowns in their systems.

Anyone who is interested in objective information and good safety points on
medication use and administration can go to the Web site at http://www.ISMP.org

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD.
Never Events: Medication Errors Resulting in Patient Death or
Disability.

A nonprofit organization called the Institute for Safe Medication Practices provides objective information and good safety points about how to prevent medication errors. A list of 28 serious preventable medical errors, termed 'never events,' has been defined by the National Quality Forum. One group of 'never events' is contained under the heading of care management events. A few of the categories under this heading are somewhat controversial. However, the first category of care management events is fairly well understood by most clinicians--patient death or serious disability associated with medication errors. These errors involve wrong drug, wrong dose, wrong patient, wrong time of administration, wrong rate, wrong preparation, or wrong route of administration. This is another portion of health care that has been repeatedly evaluated and investigated, and it is probably the most complex portion of health care delivery. The process requires that a medication order from a physician go to a pharmacist, who must be able to read the order and then find the appropriate medication, dose, strengths, etc. The pharmacist then must get the medication to the nursing unit in a timely fashion. The nursing staff then must administer the medication as the order specifies. Therefore, legibility can be an issue with the handwritten prescription, especially for items such as identifying the proper drug and dosage. Computerized physician order entry can overcome some of the problems of legibility, but it creates its own set of problems, such as clicking on the wrong drug. There are technical issues with the technological cures for these types of problems, so the health care team must be aware of the types of problems involved with handwritten and computerized medication orders. A nonprofit organization called the Institute for Safe Medication Practices focuses on medication error prevention and safe medication use. They have an enormous amount of expertise, and they also have a terrific website that provides information about how to prevent medication errors, what other clinicians have lived through, and what others have found in terms of breakdowns in their systems. Anyone who is interested in objective information and good safety points on medication use and administration can go to the Web site at http://www.ISMP.org Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD. Never Events: Medication Errors Resulting in Patient Death or Disability. [text_ad]
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