Care – Medication Adverse Events

Category
Care
Topic
Medications
Type
Risk Profiles

Medication adverse events may occur in any healthcare setting and may result in significant harm to patients.  Medication adverse events may be a result of human error (e.g., knowledge deficit, lack of compliance with safety protocols), ineffective processes, physical environment.

This document contains information entered by HIROC subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Ranking / Ratings

  • Likelihood – average score 2.84
  • Impact – average score 3.63

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

  • Key policies/procedures/processes 
    • Safe medication practices and incident review committees
    • 8-rights of medication administration 
    • Point-of-care patient identification and verification (i.e. scanning patient armbands – barcodes)
    • Allergy documentation and alerts in medical record, pharmacy system, and patient armband
    • Independent double checks 
    • High-alert medication identification/list
    • Elimination of concentrated potassium solutions in clinical areas
    • ‘Do Not Use’ abbreviation list
    • Medication reconciliation (admission, transfer, discharge)
    • Best Patient Medication History (BPMH)
    • Management of patient’s own medication (including storage separate from Pharmacy dispensed medications)
    • Standardized order sets and processes to develop and review
    • Pharmacy review and oversight of prescribing (i.e. dose/concentration/contraindications)
    • Pharmacy identification and notification to prescriber of need for therapeutic drug monitoring
    • Alignment of paper orders and electronic orders
    • Formulary review
    • Look alike and sound alike medications
    • Storage locations of drugs used for topical and injectable use
    • Limit concentrations of hydromorphone in clinical areas 
    • Standardized IV solutions
    • Pre-mixed IV solutions; pre-filled syringes
    • Standardized medication labeling
    • Safe storage of medications
    • Management of narcotics and controlled substances
    • Management of neuromuscular blocking agents
      • Specialized labeling for neuromuscular blocking agents
      • Access to airway and resuscitation equipment and resources when using neuromuscular blocking agents
    • Management of cytotoxic and non-cytotoxic hazardous drugs
      • Limit location where chemotherapy agents can be administered
      • Compounding worksheets outlining PPE requirements (pharmacy-specific)
      • Make available Intravenous (IV) monographs outlining handling requirements
      • Auxiliary labels indicating cytotoxic status
      • Medical order clear identification of route for administration of chemotherapy
      • Dispensing of medication that avoids any direct handling outside of the pharmacy 
      • Limit administration of intrathecal chemotherapy to hematologists
        • Limit where intrathecal chemotherapy can be administered
  • Equipment and technology
    • Smart pump technology
      • Patient Profile Capability Error Messaging
      • Maintenance of Smart Pump Drug Libraries
    • Closed-loop medication management systems (including bar code packaging)
    • Preventative maintenance program for all IV pumps
    • Dedicated vaccine  refrigerator  with temperature monitoring log
    • Medication dispensing systems (with automated storage and retrieval)
    • Automated warning on Omnicell for high alert/high concentration medications
    • Hazardous medications secure storage containers 
    • Optimize usage of electronic solutions intended to improve medication safety
      • Computerized Physician Order Entry (CPOE)
      • Electronic medical record (EMR) allergy alerts
    • Proactive monitoring of drug shortages, alerts and recalls
  • Education/Training/Resources
    • Nursing orientation/annual medication safety education/in-services
      • Medication safety, knowledge and testing 
      • Drug calculation knowledge and testing 
      • IV smart pump knowledge and training yearly
      • High alert medication knowledge and testing 
      • Oxytocin knowledge and testing 
      • Patient controlled analgesia (PCA) pain management knowledge and testing
      • Independent double check for high-risk medication knowledge and testing
      • eFormulary knowledge and testing
      • Comprehensive skills training related to intravenous (IV) fluid therapy including early detection of IV infiltration and management of
    • Drug-related information resources available and accessible
    • Hard copy drug formulary available for downtime procedures
    • eFormulary on organization website and mobile applications
    • IV drug monograph instructions available and accessible 
    • Up to date listing of all cytotoxic/biologic agents in formulary
      • Management of
      • Safe handling and disposal of
    • Pharmacist on-call afterhours and on-site weekend coverage
    • Pharmacy order entry staff are regulated health care providers 
    • Pharmacy technicians with specialized knowledge for sterile compounding
    • Aseptic technique training for staff in compounding room
    • Code Brown/management of hazardous cytotoxic medication spills education
    • College of Pharmacy – 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)
  • Monitor mandatory reporting of adverse drug events
  • Monitor maintenance of shortage lists
  • Narcotic utilization and losses 
  • Hazardous drug spills and safety incidents to occupational health and risk department
  • Reviews of incidents and current processes 
  • Independent double check/high alert medications audits
  • IV solution concentration and volumes audits
  • Electronic medication management audits
  • Education logs
  • Audits to assess compliance with policies and processes e.g. narcotic count process and records
  • Documentation audits
  • Computerized Physician Order Entry (CPOE) audits
  • Number of patient complaints related to IV insertion, drug errors
  • Surveillance cameras in medication rooms where narcotics are dispensed
  • Smart pump errors investigations
    • Review of smart pump logs
  • Reports to MAC, Quality and other Governance committees
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.

Partnering to create the safest healthcare system

HIROC is not just a not-for-profit, we are a reciprocal. This means we are governed by our Subscribers – a group of over 800 diverse healthcare organizations across Canada. Together we share learnings and find ways to adapt to the changing nature of the industry.
Learn More
HIROC staff members