The Pharmacist’s Role in Medication Safety | PSNet As discussed in the related primer on, adverse drug events occur when exposure to a medication results in harm. Correct medication use occurs when the “five rights” are followed, meaning the right dose of the right medication is administered to the right patient, at the right time, and by the right route.
- However, this simple phrase obscures the fact that the five rights must be individualized, as they are affected by the patient’s age, medical condition, physiologic status, and other factors such as allergies.
- While pharmacists’ contribution to medication safety has been historically focused on dispensing, pharmacists’ roles have expanded as medication therapy has increased in complexity, and many patients—even those with serious illness—can now receive care in the home and in community settings.
According to the American Pharmacists Association, pharmacists in all settings have eight essential medication-related responsibilities linked to improving patient safety. These eight responsibilities and examples of how they can affect patient safety are outlined in the Table.
|Safety action||What is involved||Example of impact|
|Ensure access to medication||Evaluate ability to pay for medication; explore alternative medications or payment means||Finding patient assistance programs or working with insurers to make medication available that patients otherwise could not afford, improving adherence and safety|
|Supply medication information||Educate patients and caregivers on safe and effective medication use||Reviewing proper dosing with patients or providers can prevent medication errors and adverse drug interactions|
|Evaluate medication appropriateness||Assess medication appropriateness, effectiveness, and safety for each individual patient||Individual consideration of “five rights” in light of patient condition, medication list, age, weight, ethnicity, diet, allergies, and kidney and liver function can result in recommendations for changes in therapy or monitoring to increase medication safety|
|Improve medication adherence||Help patients take medication as it is prescribed||Reviewing how patients are using medications can result in suggestions for changes in medication, dosing, or additional therapies that improve patient adherence|
|Provide health and wellness services||Deliver direct health and wellness service||Blood pressure screenings can reveal poorly controlled hypertension|
|Medication management||Comprehensive review of patient’s full medication regimen to ensure medications work well together and avoid problems (e.g., interaction)||Pharmacist review may determine which of several medications is causing an adverse effect; simplify a patient’s medication regimen; identify gaps in reaching treatment goals; or prevent prescription of medications that have adverse interactions|
|Assess health status||Determine current patient status and medication effectiveness; provide guidance regarding medication therapy||Pharmacist may detect dangerously low or high blood pressure and recommend changes in medication therapy and thereby prevent harm|
|Coordinating care transitions||Coordinate medication management across care transitions; assist with care coordination for transitions||Pharmacist-led medication reconciliation may identify potential interactions or omissions from medication list at transitions in care, which are prone to error.|
|Source: Pharmacists’ Impact on Patient Safety: A Joint Project of the American Pharmacists Association Academy of Pharmacy Practice and Management and Academy of Pharmaceutical Research and Science. Washington, DC: American Pharmacists Association; 2016.|
Pharmacists also have a in planning and leading medication safety programs and improvement initiatives within health care organizations. These initiatives may include developing risk-specific protocols for high-alert medications; identifying and evaluating high-risk processes (e.g., total parenteral nutrition, compounding, pediatric dose preparation) that require special attention, protocols, and training; evaluating medication error data; evaluating and implementing new medication technologies; and fostering robust error reporting processes.
- 1 What is a medication safety pharmacist?
- 2 What are the 5 steps of medication safety?
- 3 Why is medication safety so important?
- 4 What is the role of a community pharmacist in medication safety?
- 5 What are the 6 R of medication safety?
- 6 What are the 3 safety checks of medication administration?
- 7 What are the 4 principles of medicines?
- 8 What are the 4 types of medication orders?
- 9 What are the three common causes of medication errors?
- 10 What is the meaning of safe medication administration?
- 11 What is the role of a pharmacist in medication therapy management?
What is medication safety?
Medication safety is defined as the freedom. from accidental injury due to medical care or. medical errors during the medication-use. process, deserves the same prioritization, given the scope of medication use in patient care and the frequency and severity of potential harm.
What is a medication safety pharmacist?
The medication safety pharmacist is responsible for managing medication use safety and improvement plans. Job functions include patient and medication safety, staff development/training and medication use improvement. Current quality improvement initiatives have included:
Development and implementation of a pharmacy technician directed medication reconciliation program Adverse Drug Event monitoring through Pyxis trigger tools Assistance with implementation of an antiretroviral screening tool upon admission to prevent adverse drug events Assistance with implementation of a Basal/Bolus Insulin Regimen in place of Sliding Scale Insulin Assistance with implementation of a Hypoglycemia Nursing Protocol
Please contact Jennifer Czerwinski, PharmD, or Sylvia Slattery, PharmD, for further information on this service.
What are the 5 steps of medication safety?
The Five Rights: A Destination Without a Map As we have discussed in previous columns, errors in drug administration pose a great risk to patients. Most health care professionals, especially nurses, know the “five rights” of medication use: the right patient, the right drug, the right time, the right dose, and the right route—all of which are generally regarded as a standard for safe medication practices.
Yet many errors, including lethal mistakes, have occurred even when health care professionals were confident that they had verified these “rights.” Why does this happen? First, although these criteria are the goals of safe medication practice, they offer little guidance to health care practitioners on the appropriate way to ensure drug safety.
For instance, how does a pharmacist identify the right patient when the patient’s name and room number on an order copy are blurred and the physician’s signature is illegible? Whom should the pharmacist call for follow-up? How does a home-care nurse in an assisted-living facility identify the right patient if name bracelets are not used? Can the nurse depend on verbally questioning the patient? Unfortunately, relying on accurate information from patients has led to errors, for instance, when patients misunderstood a name or when they were confused.
- Without adequate systems in place to help practitioners achieve the goals of the five rights, errors are likely.
- The five rights, as stated, focus on the performance of individuals and do not reflect the fact that drug safety is a culmination of efforts of professionals from several disciplines; the responsibility for accurate drug administration lies with multiple individuals and reliable systems.
Some of the factors contributing to a medical team’s failure to accurately verify the five rights, despite their best efforts, include:
poor lighting. inadequate staffing patterns. poorly designed medical devices. handwritten orders. trailing zeroes (e.g., 2.0 vs.2) or using a decimal point without a leading zero (e.g.,,2 instead of 0.2). Misinterpretation of such an order can result in a 10-fold dosing error. ambiguous drug labels. lack of an effective independent double-check system for high-alert drugs.
Nurses, for example, cannot verify the identity of the patient if they have no way of knowing whether patients are actually who they say they are or whether the name on a patient’s armband is accurate. They can only verify two unique identifiers assigned to the patient upon admission to the facility—a process that the organization deems to be sufficient to confirm that the identity of the patient—before they administer medications.
reading the label requesting an independent double-check if required questioning orders for drugs and doses that are illegible or that appear unsafe using bar-code technology if it is functional
Organizations consider these procedural rules to be sufficient to verify the right drug and the right dose. Thus, the duty of the health care practitioner is not so much to achieve the five rights but to follow the procedures designed by the organization to produce these outcomes.
- If the procedural rules cannot be followed because of problems within the system, health care practitioners also have a duty to report the matter so that it can be fixed.
- Although some might think that this distinction is minor, it is helpful to consider the following.
- If we hold individuals accountable for achieving the five rights, we should then give them the authority to design their own systems for achieving these outcomes.
After all, how can we hold individuals accountable for situations and events that are not under their control? However, because organizations typically decide on the processes that are necessary for achieving the five rights, staff members who follow these procedures should not be held individually accountable for undesirable outcomes.
Improvements must be made in the systems themselves, not in the individual’s practice or behavior. The five rights are not a behavioral model for achieving medication safety; they are goals for which organizations must accept responsibility and design fail-safe ways so that the goals can be achieved.
Of course, the five rights are not the final word in medication safety. Unfortunately, managers often simply admonish health care practitioners who make an error for not following the five rights without recognizing or addressing the human factors and causes of the error originating within the system.
Likewise, regulatory agencies often penalize health care professionals if they cannot verify the five rights; such actions perpetuate the belief that individuals should be blamed. The five rights should remain as medication-use goals, but we must help practitioners achieve these goals by establishing strong support systems that encourage safe practices.
The reports described in this column were received through the ISMP Medication Errors Reporting Program (MERP). Errors, close calls, or hazardous conditions may be reported on the ISMP Web site () or communicated directly to ISMP by calling 1-800-FAIL-SAFE or via e-mail at,
Why is medication safety so important?
- Clinical governance and quality improvement to support medication management
- Organisation-wide systems are used to support and promote safety for procuring, supplying, storing, compounding, manufacturing, prescribing, dispensing, administering and monitoring the effects of medicines.
- Documentation of patient information
A patient’s best possible medication history is recorded when commencing an episode of care. The best possible medication history, and information relating to medicine allergies and adverse drug reactions are available to clinicians. Continuity of medication management A patient’s medicines are reviewed, and information is provided to them about their medicine needs and risks.
What is the role of a community pharmacist in medication safety?
What roles does a community pharmacist play in patient safety? – Historically, the concept of the “five rights” has been used to describe the steps that lead to safe medication use: the right dose of the right medication taken by the right patient at the right time and by the right route.
However, this concept is oversimplified, as there are additional steps of safe medication use that should also be considered; steps that are dependent on the context in which the medication-related process is occurring. Each part of the medication use process may contain different numbers and types of “rights”.
For example, in the community pharmacy setting, outcomes like the right education, right monitoring, right documentation, and right drug formulation may also be considered. The modern concept of medication safety is much broader in scope than the “five rights” and the focus has subsequently shifted with an increased emphasis placed on the contribution of systems factors to medication safety.
- Factors not directly related to medications are considered, including how the workflow, technologies, policies and procedures, and other systems factors support the outcomes of the various rights, rather than focusing solely on completion of an oversimplified checklist.
- Pharmacists in the community similarly to how they would in any healthcare environment: throughout the medication-use process, including the ordering of medications to their storage, transcription, preparation, dispensing, counseling, and more.
Prior to the dispensing process, the community pharmacist provides a clinical review of prescribed medications to ensure the therapies are appropriate. This review includes dosing appropriateness, interactions with other prescribed medications, contraindications, and more, while also considering that medications may have been ordered by multiple prescribers.
The pharmacist also provides critical monitoring in the dispensing of controlled substances, such as consulting prescription drug monitoring programs to look for patterns that might indicate abuse or diversion and to screen for potentially fatal interactions between medications that may come from multiple prescribers.
Pharmacists must identify patients at risk for fatal overdose and facilitate access to the emergency opioid reversal drug Narcan® (naloxone) as well as substance abuse treatment services when appropriate. A clinical review is essential for all prescriptions and can help ensure that any errors occurring as a result of the care transition process are caught and corrected before the medication is dispensed.
- For example, in the discharge process, the inpatient providers may have an incomplete history of the patient’s existing prescriptions when formulating the treatment plan.
- In addition, medications that may have been appropriate during the inpatient stay, but inappropriate for home use, may inadvertently be carried over into the patient’s outpatient treatment plan.
In addition to the dispensing process, the community pharmacist plays a critical patient safety role when it comes to ensuring that patients appropriately understand their medications. Community pharmacists are equipped to provide education and counseling to patients to address questions they may have regarding factors such as dosing, administration, storage, potential side effects, and how to taper medications for acute events.
Similarly, community pharmacists are an invaluable resource for supporting public health initiatives. One study found that patients visited a community-based pharmacy 35 times per year, as compared to a primary care physician, which occurs, on average, 4 times per year.2 This frequent contact with patients makes community pharmacists optimally positioned to support public health initiatives and triage concerns.
Numerous studies have proven the positive impact of pharmacists on preventative care such as health screenings and immunizations, opioid management, smoking cessation efforts, and management of chronic diseases such as diabetes.
What are the 6 R of medication safety?
6 Rights of Medication Administration Sometimes considered 5 or 6 ‘Rights’ the ‘R’s’ of medication administration are a systematic approach designed to reduce administration errors. These 6 rights include the right patient, medication, dose, time, route and documentation.
What are the 3 safety checks of medication administration?
Additional Information –
- The right patient
- The right medication (drug)
- The right dose
- The right route
- The right time
- The right reason
- The right documentation
Medication calculation: D/H x S = A ( D or d esired dosage/ H or h ave available x S or s tock = A or a mount prepared)
- When the medication is taken out of the drawer
- When the medication is being poured
- When the medication is being put away/or at bedside
- Position patient appropriately for medication administration.
- Ensure proper body mechanics for health care provider.
- Position patient safely and appropriately once medication is administered.
- Complete post assessment and/or vital signs (if applicable).
- Sign MAR; place in the appropriate chart.
- Perform hand hygiene.
What are the 4 principles of medicines?
Medicines optimisation explained – The goal of medicines optimisation is to help patients to:
improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines; and improve medicines safety.
NHS England supports the Royal Pharmaceutical Society guidance Medicines Optimisation: helping patients make the most of medicines, which has been developed in collaboration with patients, the medical and nursing professions and the pharmaceutical industry. NICE has also published guidance: Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes.
What are the 4 types of medication orders?
Reviewing Pertinent Data Prior to Medication Administration – Prior to the administration of medications, the nurse must check and validate the medication order, and also apply their critical thinking skills to the ordered medication and the status and condition of the client in respect to the contraindications, pertinent lab results, pertinent data like vital signs, client allergies, and potential interactions of the medication that is to be given.
A complete medication order must include the client’s full name, the date and the time of the order, the name of the medication, the ordered dosage, and the form of the medication, the route of administration, the time or frequency of administration, and the signature of the ordering physician or licensed independent practitioner’s signature.
The four general types of medication orders are stat orders, single orders, standing orders and prn orders. Stat medication orders are administered immediately and only once; single orders are also given only once but not necessarily immediately; a standing order is an order for a medication that will be given at specific times until it is discontinued by a doctor’s order or by default when a facility’s policy states that all standing orders are automatically discontinued after 7 days unless the physician has reordered the medication.
A prn order indicates that the ordered medication is only given when a specified condition, like pain or nausea, is present. All incomplete, questionable and/or illegible orders must be questioned and validated by the nurse transcribing the order before it is administered to the client. This questioning and validation requires that the registered nurse use, integrate and apply their critical thinking and professional judgment skills.
Automated order entry using a computer eliminates some medication order errors including those that result from illegibility of handwriting and ordering a medication with which the client is allergic to, however, nurses should never assume that this is the case.
- For example, medications that have sound alike names and medications that are similar in terms of their correct spelling can remain at risk even when computerized, automatic order entry is used.
- Medication orders are often transcribed by hand onto a medication administration record (MAR) or Medex, when the facility is not using computerized order entry.
The client’s allergies are determined, all contraindications for the medication as based on the client’s health problems and disease conditions are determined, pertinent diagnostic laboratory results such as checking the client’s prothrombin time and partial thromboplastin time prior to the administration of heparin, client data like a blood pressure and a pulse rate prior to the administration of an antihypertensive medication and digoxin, for example, are assessed and any possible interactions with other medications, foods and alternative and over the counter preparations are assessed in order to determine whether or not the medication should be administered.
What are the three common causes of medication errors?
What are Medication Errors? – The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following as its working definition of medication error: “. any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient, or consumer.
- Such events may be related to professional practice, health care products, procedures, and systems including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”.
- This concept paper focuses on the types of medication errors that take place in the ambulatory setting-that is, among patients who self-administer their medications, rather than those patients receiving medications in a clinic or hospital setting.
The types of errors that occur in this environment differ from those that occur in institutional settings; this paper will not address the issues and efforts undertaken by pharmacy colleagues in those practice settings. How Do Medication Errors Occur? The provision of drug therapy by a medical provider to a patient is a complex process.
- Errors can occur at any step along the way, from prescribing to the ultimate provision of the drug to the patient.
- Common causes of medication error include incorrect diagnosis, prescribing errors, dose miscalculations, poor drug distribution practices, drug and drug device related problems, incorrect drug administration, failed communication and lack of patient education.4 One of the largest causes of therapeutic medication misadventures is incorrectly prescribed medication.
The number of patient deaths resulting from drug errors has increased from 198,000 in 1995 to 218,000 in 2000. The cost of these misadventures to the US economy is more than $177 billion per year.5 Preventable errors occur because systems for safely prescribing and ordering medication are not appropriately used.
A widely recognized cause of error is illegible handwritten prescriptions. Errors may result from insufficient or missing information about co-prescribed medications, past dose-response relationships, laboratory values and allergic sensitivities. Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex. When prescriptions are transmitted orally, sound-alike names may cause error. Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten. Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient. Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review.
The term dispensing error refers to medication errors linked to the pharmacy or to whatever health care professional dispenses the medication. These include errors of commission (e.g. dispensing the wrong drug, wrong dose or an incorrect entry into the computer system) and those of omission (e.g.
failure to counsel the patient, screen for interactions or ambiguous language on a label). Errors may be potential – detected and corrected prior to the administration of the medication to the patient.6 The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications.
Errors caused by drug administration can be made by the health care provider or by the patient themselves. Much of the problem in drug administration is communication. Patients are often unaware that errors can happen and often do not take an active role in understanding what is being communicated to them.
Errors most often occur when communication is unclear regarding: drug name, drug appearance, why the patient is taking the drug, how much and how often to take it, when is the best time to take it, how long to take it, what common side effects could occur, what to do about a missed dose, common interactions with other drugs or foods, and whether this new drug replaces or augments other therapy.
Over-the-counter medications can lead to medication errors because labels may not be sufficiently read or understood, and health care providers are often unaware when patients are taking over-the-counter medications. The types of errors described above are primarily errors of commission.
There are also errors of omission, such as the failure to administer a drug that was prescribed or not administering a drug in a timely manner. Although they are much more difficult to identify through systematic reporting tools, errors of omission must also be addressed through process improvement efforts in order to truly improve patient safety in a comprehensive manner.
Attitudes About Medication Errors Medical professionals, including physicians, nurses and pharmacists, do not deliberately commit medication errors. They are trained to deliver “error free” health care. However, when errors are discovered, there is an attitude of placing “blame” on the professional(s) involved in the incident.
Formal punishment by the individual’s profession is sometimes administered, resulting in fines, license suspension or even license revocation. More importantly, the individual may be punished by the lost respect of his or her fellow health care professionals, which may be even more devastating than a professional reprimand.7 Where medication errors are concerned, the question of who was involved is of less importance than what, how and why the system went wrong.8 An investigation of medication errors should begin with an analysis of the drug use and delivery channels within a health care system, rather than result in punitive action directly targeted to the health care provider involved with the error.
Although there is no acceptable level of error within the medical care system, the goal of health care organizations should be to evaluate errors when they occur and to make changes in the drug delivery process to prevent them from reoccurring in the future or elsewhere.
AMCP encourages all medical professionals to take responsibility in efforts to identify, monitor, evaluate and prevent medication errors, and believes that managed care organizations should establish a nonthreatening, non-punitive and confidential environment that encourages health professionals to report medication errors in a timely manner.9 Reporting Medication Errors Health care professionals and consumers have the opportunity to report the occurrence of medication errors to a variety of organizations.
Examples include the Institute of Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA). These organizations collectively review error submissions. Case reports are published to educate health care professionals regarding errors and near errors.
In some cases, the FDA may work with drug manufacturers and others to inform them about concerns with pharmaceutical labeling, packaging and nomenclature to make appropriate changes to reduce the risk of medication errors.10 AMCP has voiced support for a medication error reporting system that encourages participation and provides confidentiality and protection of the information reported and the person(s) reporting.
To be successful a medication error reporting system must have protections for those reporting. Often, pharmacists view mandatory reporting laws and regulations as punitive, especially if public disclosure is included. Compliance with such programs is likely to be less than optimal since the results of reporting could include lawsuits, regulatory enforcement actions, forfeiture of pharmacy license, and loss of professional reputation with accompanying loss of business.11 Regulatory and advocacy activity provides for improving monitoring of medication errors.
- The FDA MedWatch reporting system provides a comprehensive sentry position for many medication errors to be reported.
- Although designed primarily for reporting adverse events from medication use, FDA’s MedWatch is an appropriate venue to discover medication errors, such as prescribing misadventures and look-alike, sound-alike errors leading to adverse reactions.
Many state boards of pharmacy have begun medication error reporting initiatives to detect trends in ambulatory dispensing errors. At this point in time, most are limited to mandatory internal reporting systems within a setting, as is the case in California, where errors must be logged and open for board inspection during routine visits and complaint investigation.
- Many physician boards and associations participate in prescribing error investigations, driven primarily by peer review and consumer complaint resolution.
- Managed Care Pharmacy and Medication Errors The vast majority of prescriptions filled in the United States are paid for and administered by managed care organizations.
These organizations can influence health care providers and their professional societies as well as consumers to encourage medication error reporting and prevention. Quality improvement programs within managed care organizations include mechanisms for reporting medication errors, examining and evaluating causes of errors, analyzing aggregate data to determine trends and making necessary changes within their health care delivery system to prevent errors from occurring.
What is the meaning of safe medication administration?
Chapter 6. Non-Parenteral Medication Administration Safe and accurate medication administration is an important and potentially challenging nursing responsibility. Medication administration not only requires understanding medications, how they work, side effects, and significant nursing considerations, it also involves good decision-making skills and clinical judgment.
- Nurses must understand why patients take particular medications, anticipate potential med-med interactions, and assess individual patient response.
- Nurses are human, so naturally medication errors do happen.
- The Joint Commission (TJC), a non profit organization that accredits health care organizations and programs, defines medication errors as any preventable event that may cause inappropriate medication use or jeopardize patient safety (TJC, 2012).
Medication errors have a substantial impact on health care in Canada (Butt, 2010) and are the number-one error in health care (Centers for Disease Control, 2018). In one study looking at drug related hospital admissions and emergency department (ED) visits, Zed et al.
2008) found that adverse drug reactions are estimated to account for more than 25% of drug-related hospital admissions and ED visits (as cited in CIHI, 2013). Of these, 68% are considered preventable. Of the patients whose ER visits were drug related, their hospital admission rates were higher and their length of stay longer when compared to patients who presented for other reasons.
Studies by other researchers reveal similar and equally concerning findings about negative medication related effects on people (Baker et al., 2004; Bell et al., 2011). The cost to patients and families, as well as to the healthcare system, points to the importance of safety in relation to all phases of the medication administration process.