Fostering a Medication Safety culture
By Adeline Saliba,
Acting Pharmacy Manager/
Senior Clinical Pharmacist
A series of reports by the Institute of
Medicine (IOM)1 have highlighted how wide the quality chasm is in healthcare and
how essential it is to close the gap between what we know are best standards of
practice and what is actually being delivered as care to our patients.
- To Err is Human2 (2000) revealed that an estimated 98,000 deaths per year
resulted from medical errors, with about 7% occurring from medication errors.
This appalling statistic placed patient safety on the radar screen of many
- Crossing the Quality Chasm3 (2001) provided a more comprehensive review of
healthcare quality and defined the six goals of healthcare: safe, timely,
effective, efficient, equitable and patient-centred care.
From these publications, it is evident that healthcare is multifaceted and
requires a collaborative approach. Redesigning care delivery through workflow
efficiencies, encouraging implementation of information technologies, and
reforming healthcare professional education are crucial to optimising quality of
care and patient safety. Emphasis must also be placed on nurturing a just
culture, supported by hospital administration and leadership, to ensure a
balance between systems and people, all while taking into consideration
professional accountability (illustrated in figure 1). Risk reduction strategies
and safety nets should be integrated into our system designs so that individuals
involved in these complex processes are able to make safe choices. Additionally,
flattening the hierarchy facilitates effective communication so that staff,
regardless of their position, feels comfortable in speaking up if they identify
A common misconception is that medication management is the sole responsibility
of pharmacists. However, due to its complexity, it takes a multidisciplinary and
collective approach to enhance our systems, as diverse stakeholders touch upon
medication management in one way or another. It is also fundamental to align
people and processes, with the right technology, to warrant appropriate, safe
and efficient handling of drugs. In fact the Joint Commission International4,
one of the predominant accrediting bodies in the region, dedicates an entire
chapter on medication management and use (MMU) through which established
standards provide direction for safe handling of drugs.
The Swiss cheese model (depicted in figure 2), proposed by James Reason,
highlights the importance of incorporating safety nets into our processes
(pictured as the “solid” part of the cheese) to prevent potential errors
(pictured as the “holes” of the cheese) from initiating, accumulating one after
the other, and propagating to finally terminate in an actual error that reaches
the patient and potentially causes harm.
Any medication managed inappropriately can have an undesirable effect on
patients. Considering examples of latent errors such as wrong drug selection,
illegible handwritten prescriptions and poor drug labelling amongst others, it
is evident that errors can occur at any point or any time in the complex
medication management process. As such, it is the responsibility of each one of
us to be attentive to unsafe practices and potential errors, but more
importantly to speak up about such defects, and to report them for investigation
and risk mitigation. Some risk reduction strategies for each of the steps of the
medication management and use process are listed below:
Drug selection and procurement:
- The multidisciplinary Pharmacy and Therapeutics Committee should determine
which medications are to be made readily available within an organisation, given
the scope of services provided. This consists of the formulary which should be
reviewed at least once a year and must take into consideration not only
medication safety and efficacy, but also cost-effectiveness of pharmacotherapy.
- The pharmaceutical procurement process should incorporate a mechanism to
ensure that drugs purchased not only undergo technical and financial
assessments, but also risk/safety scoring. For example, when selecting an
injectable medication, it is best to choose a product that consists of minimal
steps during the preparation. As such, a pre-mixed ready to use formulation is a
safer alternative to a drug that comes in a vial as a powder which needs
reconstitution and maybe even further dilution.
Adopting a computerised prescriber order entry (CPOE) system eliminates
illegible handwriting and unapproved abbreviations. With an appropriate build
that incorporates clinical decision support, CPOE also provides allergy alerts
and dose range checks just to name a few.
- Utilization of tall-man lettering, which consists of a combination of lower
and upper case fonts, allows for differentiation of look-alike sound-alike
medications to reduce confusion between such similar drugs; for example,
DOBUTamine and DOPamine.
Preparation and dispensing:
All prescribed medications must be verified by a pharmacist prior to
preparation/ dispensing and administration, with the exception of those utilized
in emergency codes.
- Implementation of automated solutions for unit-dose packaging of oral solid
and liquid dosage forms ensures that drugs are dispensed in the most ready to
administer format. Additionally, including barcodes on drug labels facilitates
barcoded medication administration at the bedside.
- Using automated dispensing cabinets for medication distribution provides
safety benefits by ensuring compliance with regulations through enhanced drug
management and security.
- Intravenous (IV) admixtures should be prepared in a cleanroom, except if used
in emergency situations.
- Preparation of total parenteral nutrition (TPN) bags prepared through a
closed-system such as an automated compounder can reduce the risk of
- Dispensing of oral medications should always be drawn up in dedicated slip tip
(oral) syringes, and injectables in Luer lock syringes to prevent inadvertent
mix-ups with regards to route of administration. Administration: Medication
administration should be in compliance with the 5 rights of medication
administration to ensure that the right drug, in the right dose, by the right
route gets to the right patient, at the right time.
- Barcoded medication administration implies scanning of the patient’s wristband
and the medication’s barcode at the bedside to reinforce these 5 rights of
- To ensure continuity of care and accurate communication, appropriate and
timely document on the patient’s medication administration record must take
- High alert medications, drugs which if involved in an error can lead to
significant patient harm, require an independent double check to avoid any
- Patients should be monitored to assess their clinical response to
pharmacological treatment modalities, and to modify regimens accordingly.
- Additionally, they should be observed for any adverse drug events whether near
misses, medication errors or adverse drug reactions.
- A medication reporting tool should be established for reporting and
investigating incidents, and for identifying trends. Publishing a monthly
newsletter could serve as a communication tool to share lessons learned.
Medication management systems are complex: its processes must be carefully
evaluated in order to introduce the sufficient and appropriate safety nets
required to prevent errors from occurring, but more importantly to avoid any
unnecessary patient harm. To ensure continuous quality improvement, it is highly
recommended that a gap analysis be conducted periodically to identify problems
across the entire medication management process. Self-assessment tools such as
the ones available through the Institute for Safe Medication Practices (ISMP)5
also provide guidance with regards to safer medication practices.
While innovative technologies can eliminate some of these gaps, they are not a
cure-all solution. Focus must be placed on system enhancements whereby it
becomes difficult to do the wrong thing and easy to do the right thing. When
implemented appropriately, not only does automation allow for incorporation of
safety nets into our systems, but it can also lead to optimised allocation and
utilization of resources as healthcare professionals are able to spend more time
for direct patient care. Such initiatives should be aligned in a way to maintain
an uninterrupted interface between the healthcare providers and the patients. By
streamlining medication management related processes and reflecting these in
policies and procedures, standardisation of practices across the entire
healthcare system will be much easier to achieve.
Considering the intricacy of medication processes, it is clear that medication
safety is the responsibility of all and must be addressed in a multidisciplinary
approach, including the patients as they too play an important role in their
plan of care. In fact, they are our biggest stakeholders. They are the ones
seeking advice to improve their medical condition, and they are at the centre of
the medication management process. To optimise their treatment, it is vital that
a partnership be created between healthcare providers and patients, in an
attempt to empower and educate patients so that they become proactively engaged
in their care. By providing them with the appropriate counselling and
educational leaflets, patients are more likely to be compliant with their drug
regimens, and will hence benefit from optimised outcomes.
Successfully accomplishing medication safety initiatives requires commitment of
both clinical and administrative stakeholders, through solid teamwork efforts
and valued communication, to ensure patients ultimately receive safe and
efficient care. When system enhancements are made, the key thing is to educate
healthcare providers about the relevance of these and to sustain changes through
1 Institute of Medicine: www.iom.edu
2 To Err is Human: Building a Safer Health System. Committee on Quality of
Health Care in America, Institute of Medicine. Washington, D.C.: National
Academy Press; 2000.
3 Crossing the Quality Chasm: A New Health System for the 21st Century.
Committee on Quality of Health Care in America, Institute of Medicine.
Washington, D.C.: National Academy Press; 2001.
4 Joint Commission International:
5 Institute for Safe Medication Practices:
of upload: 20th Nov 2012