February 2013
PSOMediumClarity PSO Learning Series
Topic #1: Medication Safety

As one of the nation's first and most trusted Patient Safety Organizations, we understand the importance of knowledge sharing in order to improve the quality of healthcare delivery. For this reason, Clarity PSO has developed a series of educational reports that focus on the risk-quality-safety (RQS) issues we have spotted through our incident reporting data collection and analyses. Each of the reports will include our findings on a given topic and our recommendations on how to use knowledge to mitigate risk and improve patient safety. The first topic in this series is Medication Safety. 


High-alert medication lists are well known, and though they vary, many organizations see overlap in the drugs that are involved in errors and incident/event reports. These medications are identified as "high-alert" because of a combination of characteristics, including unique/strict dosing parameters, the ability to alter mental and physical status, monitoring requirements such as laboratory results, and high volume utilization. These characteristics mean that these medications are involved in either/both a relatively high number of medication-related incidents or those events that have great potential for harm. As a PSO, we are tasked with building and using the knowledge and attention surrounding these particular medications to reduce the incidence rate of errors over time. 

For reference, a list of these medications can be found at several sources, including the Institute for Safe Medication Practices (ISMP).
What We Learned

Clarity PSO conducted several studies on data reported from our client organizations. From our analyses of Common Format medication error reporting, it is clear that despite all of the attention surrounding "high-alert" medications, many of these same drugs remain the largest players in medication error reporting. Here are some examples:


Top 10 Medications Identified in Clarity PSO's Common Format Medication Error Reporting Analysis

High Alert Med Chart  

*This chart shows the frequency of medications (%) involved in medication error reporting by drug name


In our analysis, by and large, the single most problem-prone area in terms of error type is related to dosing of medications. Arguably, this is logical based on certain prescribing, preparing and administering tendencies such as:

  • The abundant use of antibiotics, particularly Vancomycin
  • The monitoring required to adjust dosing in drugs like Coumadin and Heparin
  • The monitoring of electrolytes in therapies involving drugs like Lasix or IVFs
  • Age-appropriate use and range-dosing for various narcotics
  • Weight-based drugs that are either calculated or re-calculated by the pharmacy after the initial physician order is placed
Based on our experience and knowledge, we propose the following as a means of potentially alleviating the incidence rate in error reporting:

Electronic Medical Records & Technology

  • Increase use of electronic medical records to control formulary and dosing. This includes full use of Computerized Physician Order Entry (CPOE) and appropriate use of alerts to avoid fatigue and desensitization.
  • Optimizing the extent to which bar coding is used. Bar coding practices vary by provider and many limit its potential. These are some ways providers currently use bar coding:
    • Scanning the drug at the dispensing machine to match the patient name
    • Scanning the drug at the dispensing machine and scanning the patient's ID wristband
    • Directly uploading the administration to the patient's medical record in addition to scanning the drug at the dispensing machine and scanning the patient's ID wristband

As can be expected, we often observe shortcuts and ways to find work-a-rounds in an attempt to save time, but these behaviors may increase risk to patients. Fully and thoughtfully using technology would decrease risk and significantly improve other reporting such as automated near-miss reporting. 

Well-Rounded Clinical/Administrative Safety Committees

  • Re-examine the use of nurses, physicians, pharmacists and key administrative staff/leaders through the entire medication process, from procurement to administration. We often see that clinical folks are present within these committees and safety sub-committees, but key leadership is frequently missing.
  • Comparative/benchmarking reports can create awareness around the understanding of internal data use and external data use.
  • Trending data over time (for example, quarter to quarter) and looking only at your data may tell you if you have improved since the last quarter; however, comparing your data to others may tell you that, even though you have improved with respect to your organization, you may still be a significant outlier in the industry at large. These two types of data review (internal and external) need to be done in tandem in order to obtain a full picture of your performance. This may also help to break down silos between healthcare providers and support sharing of best practices, which is a significant goal of the PSO program.
To learn more about Clarity PSO, contact us or visit our website

Clarity Group, Inc. - 8725 West Higgins Road - Suite 810 - Chicago, IL - 60631

P: 773.864.8280 - F: 773.864.8281 - www.claritygrp.com

This information is provided for informational and educational purposes only and should not be construed as financial, medical and/or legal advice. Specific questions regarding this information should be addressed to local advisors and legal counsel. � 2013 Clarity Group, Inc. All rights reserved.