Medication Safety

Across the health system, UPMC physicians, pharmacists, nurses, and other staff take a collaborative approach to medication safety.

Measures taken to prevent medication errors include:

Improving Legibility

UPMC takes an innovative approach to addressing the legibility of physician handwriting, including the development of computerized physician order entry (CPOE). In CPOE, physicians can type their orders using technology available at patients' bedsides. This eliminates the need to compiles handwritten notes in paper charts.

Consistent Prescribing Practices

Consistent use of abbreviations and prescribing practices in writing orders is stressed at all UPMC hospitals and facilities, and UPMC forbids the use of specific abbreviations in handwritten medication orders.

In writing orders, physicians must:

  • Not use trailing zeroes (1 milligram must be written as “1 mg” not “1.0 mg”)
  • Write “daily” instead of “QD”
  • Write “every other day” instead of “QOD”
  • Write out “unit(s)” instead of simply the letter “U”

UPMC pharmacists track violations and contact physicians who do not adhere to these standards.

Expanding the Role of the Pharmacist

UPMC is redefining the role of the pharmacist in its hospitals by moving pharmacists onto patient floors where they work directly with clinicians. Decentralizing the pharmacy allows pharmacists to fill orders right on the patient floor, reducing delivery times and quickly replacing missed dosages.

Pharmacists work with other members of the patient care team to suggest effective medications, preferred routes of administration, and alternative drug therapies that may pose fewer side effects. The decentralized approach also permits pharmacists to work directly with patients, meet with them prior to discharge, and discuss proper self-administration of medications.

Working With National Organizations

Pharmacists assigned to UPMC’s Drug Use and Disease State Management Program work closely with national organizations to receive timely alerts and recommendations regarding safe medication practices, and UPMC shares its best practices with others through these forums.

UPMC reviews recommendations from organizations such as the Institute for Safe Medication Practices (ISMP), and implement them where necessary. One such recommendation is “tall-man lettering” — a combination of uppercase and lowercase letters — to reduce confusion between drug names that look and sound alike. UPMC pharmacists are incorporating the use of tall-man lettering into PharmNet and other applications of eRecord.

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