Core processes for administering medications have become enormously complex, and the risk of errors and process failures has increased as a result. An error or a process failure can start a chain of events leading to an adverse drug event. Several practices have been shown to improve the overall safety of administration processes. Tools such as Failure Modes and Effects Analysis (FMEA) can identify potential failures in your own medication administration processes and show you which processes to test first to reduce the risk in your organization.

Changes for Improvement

• Provide Antidote and Recovery Strategy Information
• Label Drugs Specifically for Each Dose
• Ensure That Allergy Information Accompanies Patients
• Make Allergy Information Available in Multiple Locations
• Involve Patients in Administering Their Own Medications
• Provide Medication Reference Materials at the Point of Care
• Remove Discontinued Medications Immediately
• Use Pre-Made Dosing Charts
• Eliminate or Reduce the Availability of Multiple Medication Strengths
• Separate Drugs That Look or Sound Alike
• Have Patients Maintain Their Own Medication Administration Record (MAR)
• Conduct Independent Double-Checks on the Unit
• Use Pre-Typed Medication Records, Orders, and Flowsheets
• Implement Pharmacy-Based Dosing
• Use Expert Consultants to Guide Interventions During ADEs
• Minimize the Number of Medications Available on Units
• Computerize Medication Administration Records
• Provide Medication and Food Interaction Information
• Provide Dose Calculation Aids on Drug Labels
• Involve Patients in Medication Checks
• Use One Tablet Size for Each Oral Medication
• Conduct Adverse Drug Event (ADE) Drills
• Use Bar Codes to Identify Medications
• Prepare Non-Standard Doses in Pharmacy
• Dispense Medications in Ready-to-Use Single Doses
• Limit Over-Ride Options on Computer and Medical Device Safety Features
• Pre-Compile Responses to Adverse Drug Events