Ten Ways to Reduce Medication Errors

  1. Move rapidly to electronic medical records and computerized physician ordering, eliminating handwritten medical records and physician orders.
  2. Institute fail-safe tracking of medications to ensure that the right medication gets to the right patient at the right time. Do the same for laboratory tests.
  3. Expand use of protocols and guidelines to ensure that best practices are standardized and carried out.
  4. Maintain the practice of unit dosing for medications — i.e. the preparation in the pharmacy of each medication dose for each patient.
  5. Standardize medication procedures such as limiting the number and standardizing dose strengths of each medication, as well as times of medication administration, protocols for use of hazardous drugs, medication terminology, and names of drugs.
  6. Make it difficult or impossible for a person to do something wrong by “error proofing” — e.g. like the current use of different connections for oxygen and nitrous gas tanks to anesthesia machines so one will not fit the other.
  7. Implement bar-coding of medications and patients so that both are positively identified before a drug is given.
  8. Involve pharmacists directly in health care on the nursing unit level.
  9. Involve patients in the care process wherever possible, ensuring they understand all the medications, treatments and tests they are to receive so they can be active partners with physicians and nurses in preventing errors by verifying that they are getting the right medications or other treatments. Allow patients to self-administer pain medications.
  10. Apply information management technology as aggressively to patient management as it currently is to financial management.
The recommendations on this list are examples of the kinds of actions that will be recommended by Dr. Lucian Leape at “Examining Errors in Health Care: Developing a Prevention, Education and Research Agenda,” to be held October 13-15, 1996, at the Annenberg Center for Health Sciences at Eisenhower, Rancho Mirage, California. One of the nation’s leading experts in health care quality and a pediatric surgeon, Dr. Leape currently is Adjunct Professor of Health Policy at the Harvard School of Public Health. He is also leading an error prevention initiative for the Institute for Healthcare Improvement.