One primary goal of the Joint Commission is to improve the safety of using medications. A 2001 study of prescriptions written by 23 physicians (total 37,821 prescribed items) over a 2-month period showed that 10.2% of handwritten prescriptions and 7.9% of computer-generated prescriptions contained errors. A more recent study of ambulatory care prescriptions found that 21% contained errors. Not only are there errors in prescribing, but also many errors occur with filling of prescriptions and administration of medications. According to a 2007 report of the Institute of Medicine (IOM), medication errors are responsible for 1.5 million preventable adverse drug events each year in the United States.

In 2004, the United States alone, there were over 33,000 trademarked medications and 8000 non-proprietary medications. Even though drug companies have begun to assess new drug names for similarities to existing drugs, look-alike, sound-alike (LASA) drugs continue to be marketed—and with

so many drugs, it’s ion,almostsomeprescriptionsinevitablearewritten. In a with brand names and others with generic names, and generic names may be

similar to the brand names of other drugs. Two different drugs may have the same name in different countries, and with the increase in international travel, this poses a potential risk. There are a number of recommendations that involve storage of medications and labeling (using both generic and brand names) by pharmacies, as well as limiting the formulary, and these are outside of nursing responsibility, but nursing staff must be aware of the potential for error.

The Institute for Safe Medication Practices maintains a list of LASA drugs that have been involved in patient medication errors. Link:

Institute for Safe Medication Practices list of confused drug names

Another area of concern for medical errors is administering intravenous drugs, especially when adding drugs to intravenous solutions as many drugs and IV fluids are incompatible. Drug/IV fluid incompatibility can result in crystallization of the medication, causing clogging of the lines or embolus. Additionally, if more than one drug is administered intravenously, there may be incompatibilities between drugs. Tissue damage from drugs can occur if IV lines have infiltrated, so patency of the line should be assured before injecting medications into the line. Procedures for flushing IVs before and after administration of drugs must be followed carefully. Charts with IV fluid/drug compatibilities must be available for nursing staff.

The Joint Commission is particularly concerned with increasing safety of anticoagulation therapy because of its potential for adverse effects. Standardized practices that include patient involvement are to be developed with full implementation by January 1, 2009.

Preventing medication errors

Follow the 5 rights of medication administration:

Right patient

Right drug

Right dose

Right time

Right route

Utilize correct procedures for telephone/verbal orders, such as read-back.

Question/clarify any order that raises concerns.

Follow correct patient identification procedures every time giving medications/ intravenous fluids.

Verify pediatric doses of medications.

Check intravenous fluid/medication compatibility charts when administering intravenous medications.

Check required infusion rates for intravenous medications. Read the label every time a medication is accessed and prior to administration.

Use single-dose packaging whenever possible.

Check the purpose of the medication before administration and compare with the diagnoses.

Always verify blood type before administering blood products.

Check all medication delivery devices and equipment, such as PCAs, to ensure they are set and functioning correctly.

Wrong-route

Tubings, catheters, and syringes all lend themselves to wrong-route errors in administration. In the United States, 9 cases of tubing misconnections (7 adults, 2 infants) have been reported to the Joint Commission Sentinel Event Database (launched in 1996), resulting in 8 deaths and permanent loss of function in the remaining victim. Additional reports have been made to other agencies, indicating that this is not an isolated problem, and less serious errors may go unreported. This problem arises because people often have multiple access devices (enteral feeding lines, central lines, peripheral IV lines, Foley catheters, NG tubes, epidurals and peritoneal dialysis catheters) and these devices often connect to each. There are a number of factors that contribute to the problem:

• Luer connections are often used to link various types of medical devices.

• Dissimilar tubes may be positioned close to each other (such as an enteral feeding tube and intravenous line).

• Routine use of devices for unintended purposes, such as using a syringe to administer oral medications or using intravenous extension tubing on epidurals.

• Patient hands-off without providing adequate information.
• Carelessness, fatigue, and stress.

In some cases, such as administering an IM medication subcutaneously, there may be local irritation or problems with absorption, and while usually not life-threatening, these are still serious errors. Some other specific examples of wrong-route errors include:

• Connecting an enteric feeding into an IV catheter.
• Connecting a blood pressure insufflator tube to an IV catheter.
• Injection of intravenous fluid into a tracheostomy cuff inflate tube.

• Injection of oral medication (drawn up in a syringe) into an intravenous line.
• Injection of epidural medications into an intravenous line.
• Injection of intravenous medications into an epidural line.

Because of concerns, manufacturers are producing devices with built-in barriers, such as enteral feeding tubing that is incompatible with other types of tubing or attachments and oral administration syringes that cannot attach to intravenous or other tubing. These should be used universally, but this is not yet the case, partially because of costs involved. A cost-benefit analysis may not indicate return on the investment—small comfort to patients or families who are victims of error. Additionally, there may be lack of awareness of the potential problems. However, there are a number of steps that can be taken to reduce wrong-route errors: