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Improve Core Processes for Ordering Medications:
Eliminate or Reduce Availability of Multiple Strengths

Multiple strengths of medications provide clinicians with the flexibility they need to meet the needs of different patients. However, having multiple strengths of the same medications available increases the risk that the clinicians will select and either dispense or administer the wrong strength. Such errors have a high risk of escaping detection because the name of the medication will be correct, although not the dose. By providing only one strength, or as few strengths as possible, of each medication, an organization can reduce the risk of these errors.


Tips
  • Choose which strength or strengths to make available by reviewing medication order histories to see which strengths are ordered most frequently.
  • Get comments and approval from physicians in narrowing the list of possible strengths to make available.
  • Store as few strengths as possible on patient care units.
  • If it is important to have a rarely used strength available, dispense it to patient care units only when ordered.
  • Develop a process for handling orders for other strengths.
  • Monitor the frequency of orders for other strengths - it may indicate a need to offer a different standard range of strengths.
  • Store multiple strengths separately and with clear labels to minimize risk of selection errors.
  • Include only the strengths available on computerized ordering screens, pre-printed orders, and other methods of ordering.