(Safe) Medication Administration Bundle

Harmful medication errors represent a serious concern. US data demonstrates that we fill an average of 12 prescriptions per person per year, totaling more than 4 billion prescriptions annually.

Hospitalized patients receive about 20 medication doses daily and are subject to one medication error per day, many of which are never reported.

Medication errors cause at least one death every day and injure 1.3 million people annually.

Ten key elements “bundles” that significantly influence safe medication use have been identified by ISMP (Institute for Safe Medication Practice).

Patient Information

Providing a patient’s unique identifiers and essential demographic information (e.g. age, weight) and clinical information (medication histories, medication list, allergies, vital signs, lab results)

ISMP Med Safety Core Characteristic #1:
Essential patient information is obtained, readily available in the useful form, and considered when prescribing, dispensing, and administering medications, and when monitoring the effects of medications.

Drug Information

Essential drug information (e.g., maximum dose, typical dose, precautions, contraindications, special warnings, drug interactions) is accurate, accessible and in a useful form for ordering, dispensing or administering medications.

ISMP Med Safety Core Characteristic #2:
Essential drug information is readily available in a useful form and considered when prescribing, dispensing, and administering medications, and when monitoring the effects of medications.

ISMP Med Safety Core Characteristic #3:
A controlled drug formulary system is established to limit choice to essential drugs, minimize the number of drugs with which practitioners must be familiar, and provide adequate time for designing safe processes for the use of new drugs added to the formulary

Additional Resources

Communication

Methods of communicating drug orders and other drug information are standardized and/or automated to minimize error risk. (e.g., unclear, illegible, incomplete and/or confusing orders by the prescriber or on MAR; abbreviations misunderstood; failure to communicate orders to pharmacy; unclear/ misheard verbal order)

ISMP Med Safety Core Characteristic #4:
Methods of communicating drug orders and other drug information are streamlined, standardized, and automated to minimize the risk for error.

Standard Work

Policy
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Policy
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Drug Labeling, Packaging, and Nomenclature

Labels clearly identify doses on all medication containers and drugs labeled up to point of administration. Minimize confusing /similar labels, packages or drug names. (e.g., look-alike, sound-alike)

ISMP Med Safety Core Characteristic #5:
Strategies are undertaken to minimize the possibility of errors with drug products that have similar or confusing manufacturer labeling/packaging and/or drug names that look and/or sound alike.

Drug Standardization, Storage and Distribution

Drug storage, stock, standardization, and distribution (e.g., storage of unit stock medications and pharmacy dispensed medications, use of standardized concentrations, and pharmacy delivery services)

Standardizing drug administration times, drug concentrations, IV solutions, and limiting the dose concentration of drugs available in patient care areas. Nursing transmission of orders and pharmacy delivery services support timely administration.

ISMP Med Safety Core Characteristic #6:
Readable labels that clearly identify drugs are on all drug containers, and drugs remain labeled up to the point of actual drug administration.

ISMP Med Safety Core Characteristic #7:
IV solutions, drug concentrations, doses, and administration times are standardized whenever possible.

ISMP Med Safety Core Characteristic #8:
Medications are provided to patient care units in a safe and secure manner and available for administration within a time frame that meets essential patient needs.

ISMP Med Safety Core Characteristic #9:
Unit stock is restricted.

ISMP Med Safety Core Characteristic #10:
Hazardous chemicals are safely sequestered from patients and not accessible in drug preparation areas.

Policies
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Medication Delivery Device Acquisition, Use and Monitoring

e.g., infusion pumps, implantable pumps, oral and parenteral syringes.

Assessment of drug delivery devices should be ongoing. Independent double-checks to prevent device-related errors such as selecting the wrong drug or drug concentration, setting the rate improperly, or mixing the infusion line up with another.

ISMP Med Safety Core Characteristic #11:
The potential for HUMAN ERROR is mitigated through careful procurement, maintenance, use, and standardization of devices used to prepare and deliver medications.

Standard Work

Policies
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Environmental Factors and Workflow

Environmental factors that contribute to medications errors include poor lighting, noise, interruptions, and a significant workload resulting in the task and mental overload

ISMP Med Safety Core Characteristic #12:
Medications are prescribed, transcribed, prepared, dispensed, and administered within an efficient and safe workflow and in a physical environment that offers adequate space and lighting, and allows practitioners to remain focused on medication use without distractions.

ISMP Med Safety Core Characteristic #13:
The complement of qualified, well-rested practitioners matches the clinical workload without compromising patient safety.

Standard Work

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Staff Competency and Education

Practitioners maintain their competency in safe medication practices based on professional standards and participate in orientation, and ongoing education to ensure competency.

ISMP Med Safety Core Characteristic #14:
Practitioners receive sufficient orientation to medication use and undergo baseline and annual competency evaluation of knowledge and skills related to safe medication practices.

ISMP Med Safety Core Characteristic #15:
Practitioners involved in medication use are provided with ongoing education about medication error prevention and the safe use of drugs that have the greatest potential to cause harm if misused.

Additional Resources

Patient Education

Patients are active partners in the medication process. Medications are explained to patients before administration (as applicable to patient condition). They are encouraged to ask questions.

ISMP Med Safety Core Characteristic #16:
Patients are included as active partners in their care through education about their medications and ways to avert errors.

Additional Resources

Quality Processes and Risk Management

Systems and processes are designed to reduce the chance of errors or correct them before they reach the patient and cause harm. Errors reflect failures in systems/ processes or failure because of behavioral choice.

ISMP Med Safety Core Characteristic #17:
A safety-supportive JUST CULTURE and model of shared accountability for safe SYSTEM DESIGN and making safe BEHAVIORAL CHOICES is in place and supported by management, senior administration, and the Board of Directors.

ISMP Med Safety Core Characteristic #18:
Practitioners are stimulated to detect and report adverse events, errors (including CLOSE CALLS), hazards, and observed AT-RISK BEHAVIORS, and interdisciplinary teams regularly analyze these reports as well as reports of errors that have occurred in other organizations to mitigate future risks.

ISMP Med Safety Core Characteristic #19:
Redundancies that support a system of INDEPENDENT DOUBLE CHECKS or an automated verification process are used for vulnerable parts of the medication system to detect and correct serious errors before they reach patients.

ISMP Med Safety Core Characteristic #20:
Proven infection control practices are followed when storing, preparing, and administering medications.

Standard Work

Policy
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Just Culture

Each element is defined by one or more core characteristics that further define a safe medication use system. Each practitioner at WRH has the responsibility to contribute to a safer system by identifying any opportunities to enhance our medication processes.

While substantial medication safety improvements have been achieved within the last decade, opportunities still exist to improve medication safety. Widespread adoption of key safety strategies will be more effective if stakeholder groups work together to provide the necessary changes to policy, practice and staff education.

Standard Work within the Bundles

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