Establishing effective medication error strategies everywhere around the world
Specific medication safety issues are well-known to cause fatal and harmful errors in patients, despite knowledge of repeated errors and warnings. The fact that such adverse events can be prevented by using specific measures, organizational checks and balances led numerous organizations to call them “never events.” In this expression “never” is a call-to-action, rather than an attempt to blame, focusing on the main characteristics of these life-threatening events, in particular:
- recurring, likely to happen to another patient if not addressed;
- identifiable, easily recognized, clearly defined and not attributable to other possible causes;
- avoidable, by appropriate practices, measures and organizational barriers (1).
Risk reduction strategies for preventing deadly medication errors
Preventing such events from occurring is based on risk reduction strategies, here called Targeted Medication Safety Best Practices, encompassing recommendations considering the ability of reducing or eliminating the possibility of errors, making errors visible, and minimizing their consequences (2). Selecting the best error-reduction strategy is not easy (3). As illustrated below, error prevention strategy focus on human factor principles and system issues (3-6).
- High leverage strategies that ‘design out’ hazards are most effective because they can eliminate errors and associated harm. They do not rely on individual attention and vigilance. Such strategies include fail-safes and constraints, forcing functions, automation and computerization.
- Medium leverage strategies do not eliminate hazards but reduce the likelihood of errors occurring. They are relatively easy and quick to implement but need constant updating and reinforcement to maintain people’s knowledge and the currency of the process or product. These strategies are highly dependent on the behaviour of the people using the system. They include standardisation, redundancies, independent double checking, checklists, reminders, warnings, alerts and alarms, patient counselling.
- Low leverage strategies are relatively easy and often quick to implement but need constant updating and reinforcement to maintain knowledge and currency. They are more effective when combined with other medium or high leverage strategies. They include education and training, guidelines, protocols, policies and procedures, information documents.
The goal of prevention strategies should be to redesign the medication management process to make it harder for errors to reach the patient.
The first three IMSN Global Targeted Medication Safety Best Practices
Most of the attention on best medication safety practices has focused on the hospital setting (7), but serious adverse events occur in other settings, such as ambulatory practices, ambulatory procedure areas, long term care, and home care, also needing practice improvement (i.e. those related to methotrexate).
The purpose of the IMSN Global Targeted Medication Safety Best Practices is to identify, inspire, and mobilize widespread, international adoption of consensus-based best practices for specific medication safety issues. Focusing on strategies having a higher impact on preventing medication errors, high leverage strategies, such as fail-safes and constraints, forcing functions, automation and computerization, three products amongst high-alert medications were considered as emblematic of the changes in practice that should be undertaken as a priority everywhere in the world for methotrexate used in non-oncologic conditions, vinca alkaloids, and potassium concentrate injection.
Therefore, the first IMSN Global Targeted Medication Safety Best Practices are:
- Global Medication Safety Best Practice 1
Prevent inadvertent daily dosing of oral methotrexate for non-oncologic conditions
- Global Medication Safety Best Practice 2
Prepare and dispense vinca alkaloids in a minibag, never in a syringe
- Global Medication Safety Best Practice 3
Remove potassium concentrate injection from all inpatient drug storage on nursing units
While two of these are targeted for the acute care setting, the medication safety practice related to methotrexate applies to all settings. They are realistic and have already been successfully adopted by numerous organizations.
These IMSN Global Targeted Medication Safety Best Practices have been reviewed and endorsed by experts from the International Medication Safety Network, an association of medication safety organizations, pharmacovigilance centers, regulatory agencies and medication safety experts.
Acknowledgments and Disclosures. All reviewers were volunteers and received no compensation for their contribution to this work. IMSN is grateful for these volunteers and acknowledges their expertise and assistance in revising these Global Targeted Medication Safety Best Practices.
William Allan, MEd RegPharmNZ, Medication Safety Specialist, Health Quality and Safety Commission, New Zealand; Michael Cohen, Chair of IMSN, President of the Institute for Safe Medication Practices (ISMP); Helen Dowling, Australian Commission on Safety and Quality in Health Care (ACSQHC); BarbraKaryne Nchinda Fobi, International Medication Safety Fellow, ISMP; Michael Hamilton, Physician Lead and Medication Safety Specialist, Institute for Safe Medication Practices Canada (ISMP Canada); Ciara Kirke, Health Service Executive Quality Improvement Division, Ireland; Pia Knudsen, Pharmacist, Senior Patient Safety Officer, Danish Patient Safety Authority; Ursula Köberle, Pharmacovigilance analyst, Drug Commission of the German Medical Association; Christina Michalek, Medication Safety Specialist, ISMP; Maria Jose Otéro Lopez, President ISMP Spain; Gregory A. Poff, Chairman, Saudi Medication Safety Center, Saudi Food and Drug Authority; Stephen Routledge, Patient Safety Improvement Lead, Canadian Patient Safety Institute; Étienne Schmitt, Head of Programme Éviter l’Évitable (Preventing the Preventable), Prescrire, France; Diana Shipp, ACSQHC; David U, General Secretary of IMSN, Medication Safety Advisor, ISMP Canada.
- The Canadian Patient Safety Institute (CPSI). Never Events for Hospital Care in Canada - Safer Care for Patients September 2015; 11 pages. Download
- Cohen MR, Smetzer JL, Tuohy NR and Kilo CM. High-Alert Medications: safeguarding against errors. In Medication Errors. 2nd ed. Washington (DC): American Pharmaceutical Association. 2007; 317-411.
- Institute for Safe Medication Practices (ISMP). Medication error prevention “toolbox”. ISMP Medication Safety Alert! June 2, 1999; 4 (11): 1.
- Institute for Safe Medication Practices (ISMP). Selecting the best error-prevention “tools” for the job. ISMP Medication Safety Alert! Community/Ambulatory Care Edition February 2006; 5 (2) : 1-2.
- Institute for Safe Medication Practices (ISMP Canada). Designing effective recommendations. Ontario Critical Incident Learning: Improving Quality in patient safety. April 2013. Download
- Health Quality & Safety Commission New Zealand. Error prevention strategies. Medication Safety Watch February 2015; (13): 1-3. Download
- Institute for Safe Medication Practices (ISMP). 2018-2019 Targeted Medication Safety Best Practices for Hospitals Access