Steps to Prevent Medication Errors

The Institute for Safe Medication Practices recommends the following steps when using an automated drug dispensing system to help prevent medication errors:

• Consider systems that require pharmacy order entry before nurses can remove drugs from automated dispensing cabinets. Do not allow nurses to override this feature. If overrides are allowed, develop a list of drugs or drug categories, such as antibiotics, that shouldn’t be removed without pharmacy notification and clearance.

• Consider using a system with barcoding capability for drug stocking, retrieval, and administration.

• Carefully select drugs to be stocked in cabinets. Consider the needs of each unit, staff expertise and familiarity with specific drugs, and the age and diagnoses of patients being treated.

• Minimize the drug supply and stock drugs in the smallest doses and containers possible.

• Establish maximum dose ranges for "high-alert" medications, and place this list on automated dispensing cabinets for reference.

• Educate staff to remove only a single dose of the medication ordered. If not used, return the drug to pharmacy for replacement in the automated dispensing cabinet. Staff should never return drugs to cabinets.

• Develop a check system to assure accurate cabinet stocking. Checking could be accomplished by pharmacy staff members, or by staff on patient care units if they are supplied with a daily list of items added to the cabinet for verification.

• Place allergy reminders for specific drugs, such as antibiotics, opiates, and NSAIDs, on appropriate drug storage pockets or drawers.

Source: Institute for Safe Medication Practices, Bethesda, MD.