Table 2: System Responses to Prevent Potential Errors

 

Patient Information

- Positive patient ID (bracelet, verbal verification)

 

Drug Information

- References

- Computer systems

- Formulary

- Clinical pharmacists

 

Communication

- Order clarity and drug information available for users

 

 

Labeling, Packaging and Nomenclature

- Manufacturers should be informed of confusing similar labeling

- Verify all orders at time of administration (e.g. on a "cardex")

 

Drug Storage, Stock, and Distribution

- Look-alike/sound alike drugs or medication labeling should be highlighted until changed

- Avoid rapid shifting of manufacturers

- Maintain labeling to end-user

 

Device Acquisition, Use and Monitoring

- In-service

- Maintain availability of manual or user information

- Regular calibration or equipment checks

 

Environmental Factors

- Adapt - noisy or hectic environments require read-back of all verbal orders or separate personnel as recorder

 

Staff Education

- Review new medications or devices

- Introduce protocols

- Review common errors to increase awareness

 

Quality Processes and Risk Management

- RM/QI efforts

- Independent checks

- Infection Control

 

Patient Education

- Encourage patients to bring all medications (including "dietary supplements") to office and hospital visits

- Increase patient involvement in their own care

- Serves as a final check on errors that have persisted through the system

 

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