Table 2: System Responses to Prevent Potential Errors


Patient Information

- Positive patient ID (bracelet, verbal verification)


Drug Information

- References

- Computer systems

- Formulary

- Clinical pharmacists



- 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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