A resident physician places a patient’s home medications in for their admission orders during an overnight admission. They order the patient’s home medications including clobazam; however, they accidentally order clonazepam. Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring. Which of the following is the most appropriate method for preventing future similar occurrences?
Verify the patient’s home medications with the patient
Add an alert in the electronic medical system for medications that sound similar
Have nursing perform the medication reconciliation
Reprimand and educate the resident to check medications more carefully
Add an alert in the electronic medical system for medications that sound similar
A medical error occurred where 2 similar-sounding medications were confused, leading to an adverse event. The most appropriate way to prevent this error from occurring is a system-based approach, such as adding an alert in the electronic medical system for medications that sound similar.

Medical errors commonly occur in the medical system given the complexity of delivering patient care. The best way to prevent future errors from occurring is a systems-based approach where the system is built to catch errors rather than relying on the diligence of staff. In a systems-based approach, there is an algorithmic method set in place for situations where errors are common. Examples of systems-based approaches to avoiding medical errors include time-outs for procedures, use of the electronic medical record and ordering system to generate stops and checks, and built-in procedures such as a pharmacist verifying all medical orders. The best way to prevent future errors, when possible, is a systems-based approach as it does not rely solely on individuals given that individuals are fallible and may not always avoid mistakes.

Condren et al. review a systems based approach in the medical system. They note that a systems-based approach reduces medication errors. For this reason, systems-based approaches are recommended whenever possible.

Incorrect Answers:
Answer B: Entering medications only on morning rounds with multiple providers is not a plausible strategy as patients will not receive medications they may need at other times, such as overnight. It is always a good idea to verify medications with the team on morning rounds to catch any possible errors that may be missed, but this would not necessarily fix errors that occur at other times of the day.

Answer C: Having nursing perform the medication reconciliation is not the best solution in this case, as the core problem was that the wrong medication was entered due to similar-sounding medication names. However, it is always a good idea to have multiple providers (e.g., nurses, pharmacists) verify information, check this with the physician team, and then verify the dose and route of administration when giving the medication.

Answer D: Reprimanding and educating the resident to check medications more carefully is not a solution to this problem. It does not seem that the resident does not understand the pharmacology or medication prescribed but made an understandable error. Explaining the need for care is important; reprimanding the resident is not.

Answer E: Verifying the patient’s home medications with the patient should always be performed, but it would not fix this issue with similar-sounding medications. It would catch errors such as new medications that are not on the patient’s medication list or out-of-date medications remaining on the list.

Bullet Summary:
A systems-based approach is the most appropriate way to prevent future errors from occurring.