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Key Elements of Medication Use

Medication use is a complex process that comprises the sub-processes of medication prescribing, order processing, dispensing, administration, and effects monitoring. The Key Elements of the Medication Use System™  which affect the medication-use process are listed below. The inter-relationships among these key elements form the structure within which medications are used.

  1. Patient information: Obtaining the patient’s pertinent demographic (age, weight) and clinical (allergies, lab results) information that will assist practitioners in selecting the appropriate medications, doses and routes of administration. Having essential patient information at the time of medication prescribing, dispensing and administration will result in a significant decrease in preventable adverse drug events (ADEs).

  2. Drug information: Providing accurate and usable drug information to all healthcare practitioners involved in the medication-use process reduces the amount of preventable ADEs. Not only should drug information be readily accessible to the staff through a multitude of sources (drug references, formulary, protocols, dosing scales…), it is imperative that the drug information is up to date as well as accurate.

  3. Communication of drug information: Miscommunication between physicians, pharmacists, and nurses is a common cause of medication errors. To minimize the amount of medication errors caused by miscommunication it is always important to verify drug information and eliminate communication barriers.

  4. Drug labeling, packaging and nomenclature: Drug names that look-alike or sound-alike, as well as products that have confusing drug labeling and non-distinct drug packaging significantly contribute to medication errors. The incidence of medication errors is reduced with the use of proper labeling and the use of unit dose systems.

  5. Drug storage, stock, standardization, and distribution: Standardizing drug administration times, drug concentrations, and limiting the dose concentration of drugs available in patient care areas will reduce the risk of medication errors or minimize their consequences should an error occur.

  6. Drug device acquisition, use, and monitoring: Appropriate safety assessment of drug delivery devices should be made both prior to their purchase and during their use. Also, a system of independent double-checks should be used within the institution to prevent device related errors such as, selecting the wrong drug or drug concentration, setting the rate improperly, or mixing up the infusion line with another.

  7. Environmental factors: Having a well-designed system offers the best chance of preventing errors; however, sometimes the work environment contributes to medication errors. Environmental factors that often contribute to medication errors include poor lighting, noise, interruptions and a significant workload.

  8. Staff competency and education: Staff education should focus on priority topics, such as: new medications being used in the hospital, high- alert medications, medication errors that have occurred both internally and externally, protocols, policies and procedures related to medication use. Staff education can be an important error prevention strategy when combined with the other key elements for medication safety.

  9. Patient education: Patients must receive ongoing education from physicians, pharmacists, and the nursing staff about the brand and generic names of medications they are receiving, their indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and how to protect themselves from errors. Patients can play a vital role in preventing medication errors when they have been encouraged to ask questions and seek answers about their medications before drugs are dispensed at a pharmacy or administered in a hospital.

  10. Quality processes and risk management: The way to prevent errors is to redesign the systems and processes that lead to errors rather than focus on correcting the individuals who make errors. Effective strategies for reducing errors include making it difficult for staff to make an error and promoting the detection and correction of errors before they reach a patient and cause harm. 


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About ISMP

Click to learn about the Institute for Safe Medication Practices.