Common system-based causes of errors include:

1. Lack of information about the patient or the medication
   
2. Unsafe drug storage or distribution
   
3. Environmental patterns (e.g., work environment) and unsafe staffing patterns
   
4. Inadequate staff orientation, training, education, supervision, or competency validation
   
5. Inadequate patient education

III. Preventing Medication Errors

A. The Five “Rights” of Safe Medication Use

Health care providers can use the five rights of safe medication use to help avoid errors. This system helps to ensure that the:

1. right drug is administered to the
   
2. right patient at the
   
3. right time in the
   
4. right dose by the
   
5. right route of administration.
   
   Technicians should learn the five rights of safe medication use and other error prevention practices used in their pharmacy.

B. Separating inventory or using special tags or markers on shelves to highlight error-prone drugs can help avoid potential errors. For example, some pharmacies store drugs with names that look alike or sound alike separately from each other to prevent mix-ups.

C. Some manufacturers use tall-man lettering to show differences between drugs that commonly get confused for one another. For example, stock bottle labels reading “HydrALAzine” and “HydrOXYzine” highlight the differences between these otherwise similarly packaged and named generic drugs.

D. Many institutions employ “Do Not Use” lists to limit unsafe prescription writing and dispensing practices. For example, institutions may prohibit the use of error-prone abbreviations or leading and trailing zeros when writing out numbers. The Joint Commission created a list of “Do Not Use” abbreviations in 2004 for accredited organizations, which can be accessed at http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf.

E. A high-alert medication has a high risk of causing injury when involved in an error. Special storage or dispensing procedures for high-alert medications such as warfarin, insulin, or injectable potassium products can increase safety. For example, most hospitals that dispense the very concentrated U-500 insulin store it in a separate area and dispense it using special procedures. A medication error with this high-alert medication would result in a 5-fold insulin overdose and a high likelihood of dangerously low blood sugar and death. ISMP’s list of high-alert medications is available at http://www.ismp.org/tools/highalertmedications.pdf.

F. Electronic prescribing and computerized physician order entry

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