The 2013 National Patient Safety Goals Standards (NPSGS) recognize that at certain points in the health care process, a risk is present for error. Even a single error represents the risk of serious harm to the patient, with attendant negative consequences for the health care professional involved in the error. The NPSGS have been established to present procedural safeguards against the possibility of these errors. If the safeguards are consistently followed, the risk of errors will decline, with benefits to patients and health care professionals as well.The process of prescribing and dispensing medication to patients comprises a critical juncture in patient care. The process involves a number of risk points during which errors can occur. The NPSGS establish procedural safeguards in order to protect patients from medication administration errors. The standards also serve to protect health care personnel from the personal and professional consequences of making such errors. The NPSGS for medication administration involve recommendations for the following risk points: medication reconciliation, proper identification of a patient prior to dispensing medication, and correct labeling of medication once it has been removed from its original packaging.
Medication reconciliation is an important patient safety issue. Reconciliation involves obtaining information on all the medications that a patient is taking, and making sure that no duplication, incorrect prescriptions or conflicting prescriptions exist in the list of medicines. Many patients take more than one medication, and administration of medication to these patients is often complex. In order to avoid health complications from errors in medication administration, it is important that a clinician compare the medications that a patient is already receiving with new medications that have been ordered for the patient (The Joint Commission, 2012a, p. 2).
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Reconciliation of medication is done to detect discrepancies in the prescriptions for a patient. Discrepancies in medication administration can have an adverse effect on patient health outcomes. Discrepancies in the medications for a patient may involve duplication of medicines, omission of needed medications, undesirable interactions between medications, or the need for a decision by a clinician regarding whether to continue a medication (The Joint Commission, 2012a, p. 2). Clinicians use specific information to reconcile discrepancies. This may include the name of the medication, the dosage, the frequency of use (even if only occasional or as needed), the route used to administer the medication such as oral vs. intravenous, and the reason for use (The Joint Commission, 2012a, p. 2).
A second risk point for patients during medication administration involves coordination of information between health care providers regarding the medications used by a patient. Once again, a patient may be taking numerous medications, and when a patient is admitted to a care facility or visits a clinic, this information is important for planning care. Gaps in this information can result in medication administration errors. The NSPGS recommend coordinating medication information between health care providers during the transition of a patient within and outside of a health care organization in order to perform medication reconciliation (PC.02.02.01).
For example, when a patient is admitted to a hospital, it is important that the complete list of medications that they are taking is available to the admitting health care professionals. If the patient has been treated by physicians outside the hospital and has been prescribed medication by them, the admitting health care professionals need this information. The NSPGS also advises that health care professionals provide patients with education on the safe use of medications, especially if they are discharged from the care facility.
The NSPGS reminds care providers that patients need to be reminded that if one of their prescriptions is changed by a care provider, all other care providers should be informed of the change (The Joint Commission, 2012a, p. 2). New requirement in the NSPGS state that health care personnel are now required to inform the patient about the importance of keeping this information updated.
Clinicians must know whether a patient is taking medication, and which ones they are taking in order to plan the best care, and to provide appropriate treatment and services (The Joint Commission, 2012a, p. 2). The patient must be reminded of their own responsibility to inform care providers of which medications they take, and of changes to the medications.
There are five goals stated within the NSPGS regarding medication reconciliation. These are: 1) to obtain and/or update medication information for the patient upon admission, or during the first point of contact. The list of medications that the patient has been taking at home should be compared with those that have been recently ordered for the patient. Any discrepancies should be immediately resolved by a clinician. This information should be stored in a list format that is easily accessible to other clinicians.
The list should include medications that are taken only as needed as well as those taken according to a schedule. Yet patients are frequently unable to communicate this information clearly due to illness or other handicaps. Since it is often difficult to obtain this information from a patient, the NSPGS notes that a good faith effort will be considered adequate. 2) To make certain that health care facilities define requirements regarding patient medication administration. The health care facility should clearly define the type of medication administration information that will be obtained according to various settings and circumstances. This type of information includes name of drug, dosage, route, frequency of use, and purpose.
3) A qualified clinician should compare medications currently being administered to the patient with new ones that are ordered in order to detect discrepancies. 4) When the patient leaves a health care setting such as a hospital, to provide the patient or caregiver (such as family) with written information regarding medication that should be taken. 5) Inform the patient of the importance of managing their medication information so that it is updated as changes in prescriptions occur (The Joint Commission, 2012a, p. 2).
Another risk point of medication administration involves giving medication to the wrong patient. Administration of medication to the wrong patient is an error that can occur in any stage of diagnosis or treatment. In order to avoid these medication errors, the NPSGS recommend the use of at least two patient identifiers when administering medication. For banded patients, the correct identifiers to use are the patient name printed on band, and the account number of medical record number, which is also printed on the band (Compau, 2013, p. 16).
Since the patient’s room number or location is not an adequate identifier, it may not be used for this purpose (The Joint Commission, 2012b, p. 1). In health care setting such as clinics, a patient may not be banded. For non-banded patients in a clinical environment, the process for proper identification includes asking the patient to state their name and date of birth (Compau, 2013, p. 16).
Of equal importance, the NPSGS recommend that all medications that have been removed from the original packaging be labeled. These include all medication containers such as basins, syringes, and medicine cups. Medications that are transferred to containers that are unlabeled comprise a safety hazard. This action leaves a margin for error that may result in tragic consequences for the patient. It is not enough for a health care provider to assume that they know what is in the container (The Joint Commission, 2012b, p. 3). A sterile pen and label must be used to mark all solutions (Compau, 2013, p. 23).
Labeling must be done whenever a medication is transferred from the original packaging to another container. This is done so that even in a busy medical environment, with several health care professionals at work, the possibility of administering the wrong medication to a patient is reduced. Even in a procedural setting where only one medication is being used, the medication must be labeled if it is removed from original packaging and is not going to be administered immediately. This protects the patient by reducing the risk of error to a minimum.
If an unlabeled container holding medication is found, it must be discarded immediately, as a safety precaution. It is not appropriate for any health care provider to assume that they know what is in the container. Discarding the medication eliminates the risk that the medication is something other than what may be assumed. Further, even medication containers that are clearly labeled must be removed and discarded, along with the contents, when a procedure is done (The Joint Commission, 2012b, p. 3).
The NSPGS address the risk factors that are inherent in providing the highest standard of medical care for patients. The standards that address administering medication to patients are designed to reduce the likelihood of human error or lack of information from harming a patient. At certain points in the process of giving medication to a patient, the likelihood of errors rises. As the result of careful analysis of how the medication administration process is conducted, and how errors occur and have already caused harm to patients, the NSPGS have established the current safeguards.
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