Key Takeaways
- The 'Five Rights' of medication administration are: Right Patient, Right Drug, Right Dose, Right Route, and Right Time.
- Most medication errors occur during prescription transcription and dispensing, not administration.
- High-alert medications require extra verification steps due to their potential for serious harm.
- Barcode scanning and computerized prescriber order entry (CPOE) significantly reduce medication errors.
- Near-miss events should be reported and analyzed just like actual errors to prevent future incidents.
Medication Error Prevention
Quick Answer: Medication errors can occur at any point in the medication use process. Prevention strategies include the Five Rights of medication administration, barcode verification, double-checking calculations, and creating a culture of safety where errors and near-misses are reported without fear of punishment.
Understanding Medication Errors
A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. Errors can occur at any stage:
| Stage | Examples |
|---|---|
| Prescribing | Wrong drug, dose, or route ordered; drug-drug interaction not caught |
| Transcribing | Misread handwriting; incorrect entry into computer system |
| Dispensing | Wrong drug or strength selected; incorrect labeling |
| Administering | Wrong patient; wrong time; missed dose |
| Monitoring | Failure to check labs; missed adverse reactions |
The Five Rights of Medication Administration
Every medication dispensing and administration should verify:
| Right | Verification |
|---|---|
| Right Patient | Check name, date of birth, patient ID |
| Right Drug | Verify drug name matches prescription |
| Right Dose | Confirm strength and quantity |
| Right Route | Oral, IV, topical, etc. |
| Right Time | Appropriate dosing schedule |
Note: Some organizations have expanded this to the "Seven Rights" (adding Right Documentation and Right Reason) or even "Nine Rights."
Common Causes of Medication Errors
Human Factors
- Fatigue and distraction - Working long shifts without breaks
- Knowledge deficits - Unfamiliarity with medications
- Communication failures - Poor handoff between shifts
- Calculation errors - Mistakes in dosage calculations
System Factors
- Look-alike/sound-alike drugs - Medications with similar names
- Similar packaging - Drug containers that look alike
- Illegible handwriting - Hard-to-read prescriptions
- Workflow interruptions - Frequent distractions
Technology-Based Safety Measures
| Technology | Function |
|---|---|
| CPOE (Computerized Prescriber Order Entry) | Eliminates handwriting errors; provides alerts |
| Barcode Medication Administration (BCMA) | Verifies right drug, dose, and patient at point of care |
| Automated Dispensing Cabinets (ADC) | Controlled access; electronic tracking |
| Smart Pumps | IV pumps with dose-error reduction software |
| Pharmacy Information Systems | Drug interaction checking; allergy alerts |
Root Cause Analysis (RCA)
When a medication error occurs, a Root Cause Analysis helps identify:
- What happened? - Timeline of events
- Why did it happen? - Contributing factors
- How can it be prevented? - System improvements
Key Concept: RCA focuses on system failures, not individual blame. The goal is to fix processes, not punish people.
Reporting Medication Errors
Pharmacy technicians play a crucial role in error reporting:
- Report all errors AND near-misses - Near-misses provide valuable learning opportunities
- Use incident reporting systems - Most facilities have electronic reporting tools
- MedWatch - FDA's program for reporting serious adverse events
- ISMP MERP - Institute for Safe Medication Practices Medication Errors Reporting Program
Important: A culture of safety encourages reporting without fear of punishment. Underreporting is common when staff fear blame.
Which of the following is NOT one of the traditional "Five Rights" of medication administration?
A pharmacy technician notices that a medication was almost dispensed with the wrong strength, but catches the error before it reaches the patient. This is called a:
What is the primary goal of conducting a Root Cause Analysis (RCA) after a medication error?