ASHP again pushes medication safety changes

Medication-use processes under fire

Spurred by a medication error involving dangerous doses of heparin administered to the newborn children of actor Dennis Quaid, the American Society of Health-System Pharmacists (ASHP) reiterated calls for systemic changes to help reduce medication errors.

"How many wake-up calls do we need?" asked ASHP CEO Henri Manasse, Jr., PhD, ScD. "What keeps us up at night is that we know how to prevent these serious errors. Yet here we are again, facing the exact same error that killed three infants one year ago in Indiana."

Manasse said ASHP has called on hospitals and health systems to institute known safeguards and system approaches to create a fail-safe medication-use system. "Babies are being injured and even dying for no reason," said ASHP director of practice standards and quality Kasey Thompson, PharmD. "We know how to put an end to it and we must do it. Hospital boards of trustees and CEOs must take this seriously and act now. It's important to remember that there are extremely well-qualified and careful staff at hospitals throughout the country. These problems are caused by bad systems, not bad people."

ASHP recommends that hospitals institute these steps:

1. Involve pharmacists in designing and evaluating all medication-use processes.

2. Use the strongest preventive strategies, such as forcing functions or constraints, in processes involving high-risk drugs such as heparin and high-risk patients such as newborns.

3. Limit the number of concentrations of medication available on patient care units to the one most frequently used and dispense the others from the pharmacy.

4. Dispense medications in unit-dose form prepared by the pharmacy and limit, to the extent possible, any additional preparation steps before administration.

5. Always label medications with the drug name and strength if not given immediately.

6. Implement barcode bedside scanning technology.

7. Simplify and standardize processes for medication use.

8. Seek and use knowledge from other institutions that have solved similar problems.

9. Assess the potential for error during selection, storage, preparation, and administration in areas where the medication will be used, including medications in automated dispensing machines.

10. Report all actual and potential errors and use the lessons learned to improve safety of medication use.