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.