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Selecting the best error-prevention "tools" for the job
Last month’s article Drug name confusion: Let’s resolve to do better, highlighted the fact that, despite error-prevention efforts, look-alike drug names, sound-alike drug names, and look-alike packaging continue to be a common source of medication errors. Selecting the best error-prevention strategies is not an easy task. Even when system-based causes such as look- and sound-alike issues have been identified, it may be unclear which error-prevention strategies will be most effective.
Listed below and in Table 1 are examples of error-prevention strategies in order of effectiveness for creating lasting system changes for safe medication use. Those listed first are more powerful because they focus on changes to the system in which individuals operate. As the list descends, strategies that target system changes, but rely in some part on human vigilance and memory are presented. Strategies toward the end are familiar and often easy to implement, but rely entirely on human vigilance.
Fail-safes and constraints are among the most powerful and effective error-prevention strategies. They involve true system changes in the design of products or how individuals interact within the system. Examples outside of healthcare would include the inability to start a car while the gearshift is in reverse or using fingerprint verification to enter a building or computer system. At a community pharmacy where the pharmacy computer system is integrated with the cash register, a fail-safe would prevent the clerk from “ringing up” the prescription unless final verification by a pharmacist was noted in the system.
Forcing functions are procedures that create a “hard stop” during a process to help ensure that important information is provided before proceeding; often referred to as a “lock and key” design. For example, an electronic prescribing system in a physician’s office that requires the indication to be entered for each medication before it is processed and sent to the pharmacy; a pharmacy computer system that prevents overriding selected high-alert messages without a notation (e.g., entry of the patientspecific indication for selected error-prone medications); or a bar-code scanning system that does not allow final verification of a product without a positive match between the selected product and the profiled medication.
Automation and computerization of medication-use processes and tasks can lessen human fallibility by limiting reliance on memory. Examples include use of electronic prescribing software that includes clinical decision support; pharmacy computer systems that can receive prescriptions sent electronically from a prescriber’s hand-held device or computer and thus eliminate transcriptions and misinterpretations; robotic prescription preparation and dispensing technology; and computer systems that provide accurate warnings related to allergies, significant drug interactions, and excessive doses.
Standardization creates a uniform model to adhere to when performing various functions and it tends to reduce the complexity and variation of a specific process. For example, standardized processes could be created to guide the pharmacist’s final verification of a medication or to enhance the safety of giving or receiving a telephoned medication order. Prescriber use of carefully designed preprinted prescription blanks that contain commonly used protocols (e.g., steroid tapers, insulin regimens, preprocedure instructions) or frequently prescribed medications can reduce problems with confusing or missing instructions and illegible handwriting. On its own, standardization relies on human vigilance to ensure that a process is followed; therefore, it is less effective than the strategies mentioned previously.
Redundancies incorporate duplicate steps or add another individual to a process to force additional checks in the system. Involving two individuals in a process reduces the likelihood that both will make the same error with the same medication for the same patient. However, the potential for error still exists since the redundant step may be omitted or ignored...
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