Strategies offered for wrong patient med errors
Wrong-patient medication errors occur most often during administration and transcription, but patient safety can be improved by implementing strategies during all phases of the medication process, according to a new report from the Pennsylvania Patient Safety Authority (PPSA).
During the period of July 1, 2011, through Dec. 31, 2011, 813 wrong-patient medication errors were reported to the PPSA. Errors most often occurred during transcribing (38.3%) and administration (43.4%) and least during dispensing (5.2%). Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events. While multiple factors might have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers. Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, using healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.
"Wrong-patient medication errors can occur at any phase of the medication-use process," the authors write. "While events reported to the authority suggest that these errors occurred most often during administration and transcription, implementing safety strategies at all nodes can help to ensure that the correct patient receives the correct medication."
The suggested safety strategies include improving patient verification, limiting the use of verbal orders, and empowering the patient to prevent and detect medication errors. The full PPSA report is available online at http://tinyurl.com/mjon44x.
1. Yang A, Grissinger M. Wrong-patient medication errors: an analysis of event reports in Pennsylvania and strategies for prevention. Pa Patient Saf Advis 2013; 10(2):41-49.