The Medication Circuit… This title alone reflects a growing concern about improving the reliability of medication administration. This process has become quite complex due to the diversity of pathologies, interactions, computerized prescriptions, varying degrees of urgency, the range of therapies, and the involvement of different healthcare professionals in the care process.
The risks of adverse events from all causes (also known as serious adverse events or SAEs) have never been so high, as evidenced by institutional statistics on this issue.
Among these adverse events, those related to medication errors account for a significant proportion.
The 2009 ENEIS national survey on serious adverse events related to healthcare revealed that:
- Medication-related adverse events represent 32.9% of all healthcare-related adverse events,
- among medication-related adverse events, 51.2% are considered preventable and 54.5% resulted in hospitalization.*
To guarantee the safety of care, improving patient medication management is a matter of international, European, and national concern: the World Health Organization (WHO) has made it its second major priority, and the French National Authority for Health (HAS) has published a guide on this subject and has also integrated medication management into the certification of healthcare facilities since its inception, regularly strengthening the requirements in this area.
Securing medication administration to According to the French Society of Clinical Pharmacy, a medication error is defined as a “deviation from what should have been done during the patient's medication management. A medication error is the unintentional omission or performance of an act related to a medication, which can lead to a risk or an adverse event for the patient.”* In concrete terms, a medication error results from an unintentional malfunction in the organization of the patient's medication management. It can concern one or more stages of the medication circuit, such as prescription, dispensing, pharmaceutical preparation, the form and design of the medication, delivery, administration, therapeutic monitoring, as well as its interfaces such as communication. Among these different levels of implementation, the error Administration errors are the primary cause of medication errors. In 2009, according to the ENEIS survey, they accounted for more than 60% of these errors.
right patient: ensure that the correct medication is administered to the correct patient. To do this, it is essential to verify the patient's identity at each administration. If the patient's condition allows, ask them to identify themselves (name, surname, date of birth). To learn more, you can find the SafeTeam Academy article on patient identification and vigilance.
- The right medication: ensuring that the prescribed medication is given to the correct patient.
This involves taking the time to carefully read the medication label and performing three successive checks: when retrieving the medication from stock, during preparation, and before administering the medication to the patient. However, as you will discover by reading Patient Safety Report No. 18 (http://www.patientsafetydatabase.com/pdf/fr/2021-01-PSR18-fr.pdf), reading the label is not enough. Perform cross-checks and work as a team!
- The correct dose: Ensure you are administering the correct concentration, dilution, or dose of the prescribed medication.
This step involves verifying the dose calculations and, if necessary, having them checked by another healthcare professional. Knowing the "usual" doses of medications will also allow you to question the prescriber or pharmacist when the prescribed dose differs from the usual dosage.
Perform a double check if you have any doubts about the calculations, and systematically for the administration of medications considered high-risk.
- The correct route: Ensure you are using the prescribed route.
During this step, it is necessary to ensure that the route is appropriate and safe. For certain high-risk routes, such as the intrathecal route, it is recommended to request confirmation.
- The right time: ensure that administration is carried out at the right time.
Some medications are administered at specific times and frequencies. It is advisable to reconcile the patient's preferred timing with the constraints related to their treatment.
And to top it all off, in order to secure this process and allow for the proper implementation of this rule, it is essential to limit interruptions in tasks.
SafeTeam and medication errors
