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Patient Safety Authority Releases Advisory Focusing on Common Causes of Medication Errors
Date:9/27/2007

ine and hydromorphone, which account for the most common and potentially serious errors that can occur involving two high-alert medications (drugs that carry the risk of significant harm to the patient if used incorrectly).

"The risk exists in almost every healthcare facility in Pennsylvania," said Cohen. "Facilities need to assume that this error will eventually happen in their institution and consider taking the necessary steps while storing and administering the medications to reduce the risk of error and patient harm."

The strategies include: limiting hydromorphone access; reducing the number of different strengths available for each drug; reducing look-alike potential of the drug by using tall man lettering for emphasis on labels; using technology such as bar coding and automated dispensing technology to minimize the risk of error; requiring staff to double check the dose before administering; monitoring patients closely before discharge; educating staff with safety information about potent narcotics through newsletters and in-service meetings; educating patients prior to administering narcotics and repeating the name of the medication out loud to the patient as another source of confirmation.

Cohen said further evidence that facilities need to rethink how they store and administer look-alike and sound-alike drugs comes from the 13,000 reports of wrong drug medication errors collected by PA-PSRS.

"For the first time, we've listed the top twenty-five medication pairs involved with wrong drug errors in Pennsylvania," said Cohen. "I hope facilities take a look at the list and make the appropriate changes in their facilities because many of them look and sound alike which increases the risk for error."

Cohen added that the Joint Commission has established a National Patient Safety Goal (goal 3C) to assure that hospitals address commonly confused name pairs.

Of the 23% of all reports that are classified as medication errors,
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SOURCE Pennsylvania Patient Safety Authority
Copyright©2007 PR Newswire.
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