Risk Profile: Care – Medication adverse events

Risk Profile: Care – medication adverse events (PDF version)

Medication adverse events may occur in healthcare or in the home setting and may result in significant harm to patients.  Medication adverse events may be a function of human factors, human error (e.g. knowledge deficit, lack of compliance with safety protocols), ineffective processes and environmental factors. This document contains information entered by your peers in the Risk Register application to help you manage this risk.

Ranking/ratings[1]

  • Likelihood – average score 3.09
  • Impact – average score 3.26

The Risk Register allows for risks to be assessed on a five-point likelihood and impact scale, with five being the highest.

Key controls/mitigation strategies

  • Policies/procedures/processes
    • 8 Rights of medication administration
    • Point-of-care patient verification (i.e. scanning patient armbands – barcodes)
    • Closed-loop medication management (fully electronic medication management system)
    • Independent double checks
    • High-alert medication identification/list
    • ‘Do Not Use’ abbreviation list
    • Medication reconciliation (admission, transfer, discharge)
    • Management of patient’s own medication (including storage separate from pharmacy-dispensed medications)
    • Standardized order sets and processes to develop and review
    • Computerized Physician/Provider Order Entry (CPOE)
    • Pharmacy review and oversight of prescribing (i.e. dose/concentration/contraindications)
    • Alignment of paper orders and electronic orders
    • Formulary review
    • Look-alike and sound-alike medications
    • Standardized IV solutions
    • Pre-mixed IV solutions; pre-filled syringes
    • Medication labeling
    • Safe storage of medications
    • Management of narcotics and controlled substances
    • Management of cytotoxic and non-cytotoxic hazardous drugs
  • Equipment and technology
    • Smart pump technology
      • Patient profile capability error messaging
      • Maintenance of smart pump drug libraries
    • Closed-loop medication management systems (including barcode packaging)
    • Preventative maintenance program for all IV pumps
    • Dedicated vaccine  refrigerator  with temperature monitoring log
    • Medication dispensing systems (with automated storage and retrieval)
    • Hazardous medications secure storage containers
  • Education/training/resources
    • Nursing orientation/annual medication safety education/in-services
      • Medication knowledge and testing
      • Drug calculation knowledge and testing
      • IV pump knowledge and testing
      • High-alert medication knowledge and testing
      • Oxytocin knowledge and testing
      • Patient Controlled Analgesia (PCA) pain management knowledge and testing
      • Independent double check knowledge and testing
      • eFormulary knowledge and testing
    • Drug-related information resources available and accessible
    • eFormulary on organization website and mobile applications
    • IV drug monograph instructions available and accessible
    • Pharmacist on-call afterhours and on-site weekend coverage
    • Pharmacy order entry staff are regulated healthcare providers
    • Pharmacy technicians with specialized knowledge for sterile compounding
    • Code Brown/management of hazardous cytotoxic medication spills education
    • College of Pharmacists – standards of practice (i.e. Schedule II and III drugs)
    • College of Nurses – medication practice standards
    • College of Physicians and Surgeons – medication management
    • Accreditation Canada – medication management and prevention of adverse medication events

Monitoring/indicators

  • Medication incident reports/reviews/trends (including near misses)
  • Narcotic utilization and losses
  • Hazardous drug spills and safety incidents
  • Independent double check/high alert medications audits
  • IV solution concentration and volumes audits
  • Electronic medication management audits
  • Education logs

[1] As of January 1, 2017

Note: information presented in this document has been taken from the shared repository of risks captured by HIROC subscribers participating in the Integrated Risk Management program.

© 2017 HIROC. For quality assurance purposes.