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 medical conditions, drug interactions, computerized prescriptions, varying degrees of urgency, the range of therapies, and the involvement of different healthcare professionals in the care process.
The risk of adverse events from all causes (also known as serious adverse events or SAEs) has never been higher, 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 account for 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 ensure the safety of patient care, improving medication management is a priority at the international, European, and national levels: 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 incorporated medication management into the certification process for healthcare facilities since its inception, regularly strengthening the requirements in this area.
Ensuring safe medication administration 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 involve one or more stages of the medication process, such as prescribing, dispensing, pharmaceutical preparation, the form and design of the medication, delivery, administration, therapeutic monitoring, as well as related processes such as communication. Among these different levels of implementation, 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 each time medication is administered. If the patient’s condition permits, ask them to identify themselves (first name, last name, date of birth). For more information, see 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 the 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), simply reading the label is not enough. Perform cross-checks and work as a team!
- The correct dose: Make sure 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 reviewed by another healthcare professional. Knowing the "standard" doses of medications will also allow you to ask the prescriber or pharmacist for clarification when the prescribed dose differs from the standard dosage.
Double-check the calculations if you have any doubts, and always do so when administering medications considered high-risk.
- The correct route: Make sure you are using the designated route.
During this step, it is important to ensure that the route is appropriate and safe. For certain high-risk routes, such as the intrathecal route, it is recommended to seek confirmation.
- The right time: ensure that the administration is carried out at the right time.
Some medications are administered at specific times and intervals. It is advisable to balance the patient's preferred schedule with the requirements of their treatment.
And to top it all off, in order to ensure the security of this process and enable the proper implementation of this rule, it is essential to minimize interruptions in tasks.
SafeTeam and medication errors
