Safer Medication Administration Through Design and Ergonomics

Abstract

Safe medication management is a major focus of all of the stakeholders in the surgical ambulatory and hospital service arena. There are key elements which must be in place according to contemporary standards and regulatory and/or accrediting bodies. Adverse drug events cause substantial morbidity and mortality, yet they remain underappreciated and misunderstood. The terminology to describe errors and patient harm associated with medications causes much confusion. Medication errors are the number one cause of preventable adverse events, including death. System checks should be designed into the medication administration process to prevent or reduce chances of inadvertent drug/vial swap. There needs to be, among other expectations, prudent formulary management, closely managed controlled drug systems, ongoing focused education of staff, due diligence in purchasing in general and compounding pharmacy selection in specific, and unwavering support for safe injection practices. Also emphasized are the role and rationale for meaningful documentation of adverse drug events and the role of the pharmacist, along with an outline of the types of events that should be reported to regulatory agencies, pivotal in the goal of safe medication management. This chapter will be divided into two parts: Part I deals with managing adverse medication events in the operating room based upon a real event and Part II addresses ambulatory medication safety and regulatory oversight.

“Do the right thing. It will gratify some people and astonish the rest.”

—Mark Twain

Appendix 1: Contract Pharmacy and Medication Management Consultation Services