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HealthDecember 07, 2020

Ensuring medication safety in acute care: A review of interventions

By: Sarah Handzel, BSN, RN
According to a 2016 report in the Journal of Community Hospital Internal Medicine Perspectives1, preventable medication errors impact over seven million patients every year, costing almost $21 billion in healthcare costs across all types of care settings.

Errors occur at every step of the medication process, from prescribing and dispensing to administration to the patient. And almost any healthcare worker may make a medication error; nurses, pharmacists, physicians, and other medical staff members are all susceptible to medication mistakes.

Some hospital departments seem to be particularly prone to medication errors, including intensive care, emergency medicine, and surgery. Many of the current practices intended to reduce medication errors focus on specific sources of error, such as drug misidentification. Other interventions are intended to help reduce staff distraction and improve medication education, but, unfortunately, errors still occur.

The International Journal of Evidence-Based Healthcare2 completed an umbrella review to try to identify the most effective interventions to improve medication safety. These interventions may be of particular interest to nurse leaders, who can adopt these policies in their own workplace to help keep patients safe.

Four effective medication safety interventions

The Journal’s umbrella review included information gathered from sources such as MEDLINE, CINAHL, The Cochrane Library, and others. A total of 23 systematic reviews were used to single out 13 specific medication safety interventions—but the exact effectiveness of each intervention was difficult to measure.

However, four interventions were flagged as particularly effective:

  • Medication reconciliation or review – During this process, each patient’s medication orders are compared against their actual medications. This intervention showed consistent effectiveness by reducing medication errors and adverse drug events based on the findings of seven individual reviews.
    Medication reconciliation was shown to be particularly relevant to healthcare providers in acute care settings, since medications are often changed between admission and discharge. Additionally, medications are often recorded incorrectly when patients present with emergency or intensely acute care needs.
  • Specialist health professional roles – Pharmacists, especially specialty pharmacists, dramatically help improve medication safety by performing medication reconciliation and review. But they also act as important educators to other clinicians, particularly with regard to prescribing behavior.
  • Barcode administration systems – Medication safety affects every healthcare provider in each step of the process. Individuals who administer medications to patients benefit from barcode administration systems, which were shown to be consistently effective in reducing medication errors.
    The umbrella review also noted that nurses who use barcode administration systems feel more confident and organized when administrating medications. But some nurses reported dissatisfaction with system outages and errors, leading some individuals to develop ‘work-arounds’ to shortcut perceived problems, such as documenting medications as given prior to actual administration.
  • Preprinted order sheets – In many cases, preprinted order sheets are used to control the use of commonly used high-risk drugs with specific dosing regimens, such as insulin or chemotherapy drugs. In other cases, order sheets help ensure safe drug administration in emergency situations. These sheets are not subject to the same technical issues as barcode administration systems, but they may be easily ignored or forgotten in emergency or other situations.

The author of the umbrella review suggests that nurse leaders should adopt medication safety interventions showing strong evidence of their effectiveness in reducing errors. However, more research on this subject should focus on standardizing terminology and producing more rigorous experimental primary studies.

Sarah Handzel, BSN, RN
Freelance Health and Medical Content Writer, Wolters Kluwer Health
Sarah has over nine years’ experience in various clinical areas, including surgery, endocrinology, family practice, and pharmaceuticals. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers.
  1. da Silva, Brianna A, and Mahesh Krishnamurthy. “The Alarming Reality of Medication Error: a Patient Case and Review of Pennsylvania and National Data.” Journal of Community Hospital Internal Medicine Perspectives, Co-Action Publishing, 7 Sept. 2016, ncbi.nlm.nih.gov/pmc/articles/PMC5016741/.
  2. Khalil, Hanan BPharm, MPharm, PhD, AACPA. “Interventions to Ensure Medication Safety in Acute Care: an Umbrella Review.” NursingCenter, 2020, nursingcenter.com/journalarticle?Article_ID=5573943.
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