Medication Safety
According to ISMP Canada, medication safety is freedom from preventable harm. Every health care professional is responsible for ensuring the safe use of medications with patients in order to ensure that each patient is not harmed from a preventable cause.
Medication Incident
A medication incident is also known as a medication error. According to ISMP Canada, a medication incident is any preventable event that can cause or lead to the misuse of a medication or patient harm. In this definition, the medication may be in the control of a healthcare professional, patient or consumer.
A medication incident can be related to any of the following:
A medication incident can be related to any of the following:
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The key point about medication incidents or medication errors is that they are PREVENTABLE.
Stages of Medication Use
There are 5 main stages of medication use:
According to a study conducted in Ontario acute care hospitals in 2006, the highest percentage of medication errors occurred at the medication administration stage. This study found that 72.5% of actual adverse drug events and 81.6% of potential adverse drug events occurred at the stage of administration. Furthermore, this same study found that the most common type of error that occurred was the omission of a drug (that is, the patient did not receive the dose at the appropriate time). The second and third most common types of errors at the point of administration were found to be administration of the improper dose and incorrect drug, respectively.
The administration of the wrong drug to a patient can have serious consequences for a patient's health, especially if the wrong drug administered belongs to the group of high alert medications. This is because high alert medications are drugs that bear heightened risk of causing significant patient harm when they are used in error. Since narcotic drugs (opioids) are one of the many classes of high alert medications, more information about HYDROmorphone and morphine, the most commonly mixed up pair of narcotic medications, can be found by following the link to the HYDROmorphone vs. Morphine page.
- Physician ordering
- Order entry and order transcription
- Dispensing and delivery of medication
- Medication administration
- Monitoring after administration
According to a study conducted in Ontario acute care hospitals in 2006, the highest percentage of medication errors occurred at the medication administration stage. This study found that 72.5% of actual adverse drug events and 81.6% of potential adverse drug events occurred at the stage of administration. Furthermore, this same study found that the most common type of error that occurred was the omission of a drug (that is, the patient did not receive the dose at the appropriate time). The second and third most common types of errors at the point of administration were found to be administration of the improper dose and incorrect drug, respectively.
The administration of the wrong drug to a patient can have serious consequences for a patient's health, especially if the wrong drug administered belongs to the group of high alert medications. This is because high alert medications are drugs that bear heightened risk of causing significant patient harm when they are used in error. Since narcotic drugs (opioids) are one of the many classes of high alert medications, more information about HYDROmorphone and morphine, the most commonly mixed up pair of narcotic medications, can be found by following the link to the HYDROmorphone vs. Morphine page.
1. ISMP Canada. Definition of terms. http://www.ismp-canada.org/definitions.htm Accessed February 15, 2013.
2. ISMP Canada Safe Medications Use, Mistakes with medicines can happen. Are they preventable? November 1, 2012 presentation.
Available at: http://www.safemedicationuse.ca/tools_resources/tips.html. Accessed February 15, 2012.
3. Marsham JA, U DK, Lam RWK et al. Medication error events in Ontario acute care hospitals. Can J Hosp Pharm. 2006;59(5):243-50.
4. PA PSRS Patient Saf Advis 2007 Sep;4(3):89.