Defining Medication Errors
In order to resolve the problem of medication errors, it must be understood. We can start by defining what a medication error is. Several definitions exist, but for our purposes, a medication error is “...any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.”2 This definition is very broad. Many levels of seriousness exist within it; errors can be harmless, but they can also be deadly.
Now that we have a definition of what a medication error is, what is the next step? How do medication errors occur? Is someone to blame for an error? Historically, we in healthcare have tended to punish those who have committed the error. This is sometimes referred to as “shame and blame.” Unfortunately, this approach has done nothing to stem the tide of rising medication errors. Medical professionals who were involved in errors were told to “shape up” and “stay focused.” Errors weren’t viewed as problems with the healthcare system but as problems with the individual. Yet anyone who has worked in healthcare knows that there are errors waiting to happen. The Institute of Medicine (IOM) agrees with this position and has stated, “Healthcare has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try.”
Today we are more focused on a systems perspective. This method identifies places in medical policies and procedures that can be modified to prevent errors. The systems approach seeks to identify and correct these errors to prevent as many as possible before they occur. When using the systems process, no one is blamed, but instead is asked, “What could be done differently so that this does not happen again?”
What Causes an Error?
Many factors contribute to errors. Some of these factors include the mathematical skills, knowledge of medications, workload and staffing levels, policies and procedures, drug delivery systems, distractions and interruptions, and legibility of orders.4 Let’s take a closer look at some of these areas. Institutions should have ways of addressing these errors using systems methods. The systems approach can be applied to all of these sources of error, thereby making medication errors less frequent.
Dose errors are one of the most common and important administration errors.4 Dose errors may or may not involve a calculation, but studies have identified that inadequate mathematical skills can contribute to a dose error.5,6 Assessing the mathematical skills of nurses can be done during inservices and orientation periods.4 If areas of difficulty are identified, they can be addressed by management. Of course, tests are not perfect. Some examinations gauge nurses at a lower level of knowledge than needed while others only measure the theoretical knowledge of the nurse, not his or her actual performance on the job. Regardless of skill level, confounding factors such as interruptions and multi-tasking can contribute to dose errors in practice.
As administrators of medications, nurses are accountable for knowledge of medication actions, side-effects and dose ranges. Studies have shown healthcare professionals’ knowledge in these areas is often inadequate and may lead to an error being made.7,8 On the other hand, those who continually update their knowledge of drugs make fewer errors than those who do not.9,10 A commitment to lifelong learning helps patients and institutions alike.11 Yet keeping up to date with all medications can be a daunting task due to the sheer number of medications available on the U.S. market. Nursing inservices should be regularly scheduled to provide a forum for continuing education.
It seems obvious that workload can be a major factor contributing to an error. As workload increases, nurses have less and less time to spend with each patient. The number of distractions and interruptions rises. Many studies have demonstrated that errors tend to increase when patient load increases.8,12,13 Errors also occur more frequently as the shifts worked by temporary staff increase.14 Unfortunately, heavy workloads appear to be here to stay, at least for the foreseeable future. In spite of these stressful conditions, the systems approach can work to reduce the number of errors.
Other factors contribute to medication errors. The ones described above are but a sample, and many additional ones aren’t written about here. Previously mentioned factors include policies and procedures, drug delivery systems, and illegible orders. Now that we know how some errors occur, let’s talk about what can be done to decrease these errors.
Decreasing Errors: Tips From a Systems Approach
Processes should be in place to identify medical errors. Only by accurately reporting errors can something be done about them. Several papers have been written describing ways to create a better workplace environment, one that minimizes errors. It is important to remember that preventing medical errors is not solely the responsibility of any one group; physicians, nurses, pharmacists and managers all have roles to play in the process. While interprofessional teamwork is needed, each healthcare professional, including nurses, can do his or her part to prevent errors. Some suggestions are listed below.15-17
Reduce reliance on memory. The human brain has several limitations. Two of these are short-term memory and vigilance, meaning prolonged attention. Certain tools can be incorporated to decrease reliance on these fallible processes. Examples of such tools are checklists and protocols. To help decrease math and drug knowledge errors, “quick check” charts for common medication interactions or dosing can be developed. These charts can then be posted where they can be easily used as a resource and utilized as a double check.
Standardization of tasks. By standardizing the way things are done wherever possible, there is less chance for error. Conversely, if there are a hundred different ways to perform a task, there are that many ways to commit an error. Some areas where standardization has the potential to play an important role involve drug administration times and using only one kind of pump or syringe. Institutions and offices should have standard procedures in place to help staff prevent mathematical errors. For example, standard procedures should be developed and followed routinely for medication calculation. Staff should have a quiet area designated for calculating doses or have a second staff member independently calculate dose to assure appropriateness. Systems and procedures can also help nurses with drug knowledge. Standard procedures for assessing medications before procedures (such as medication reconciliation) should be developed and routinely followed. Standardization can also help decrease workload-related errors. When safe policies and procedures are developed and followed routinely, fewer errors will occur. This also works for interruptions. When a nurse is interrupted while performing a standardized task, he or she will more easily be able to resume activity without forgetting an essential component of the task.
Using constraints or forcing functions. Some errors can be prevented by literally making the error impossible to occur. We refer to so-called “forcing functions,” where healthcare professionals are simply not allowed to do certain kinds of actions. Forcing functions eliminate relying upon memory, checklists, or protocols. Computerized systems can be designed to prevent a pharmacist from entering in a lethal dose of medication or stopping a nurse from entering the wrong rate on an infusion pump. Concentrated bottles of intravenous potassium can be removed from floor stock. Another option is to use equipment that prevents inappropriate connections, such as preventing oxygen and nitrous oxide from anesthesia machines from being joined inappropriately.
Reduce the number of handoffs. Mistakes can happen when we transfer items to other people. A hospital or medical office will make fewer errors if a process can be designed that minimizes the number of handoffs between personnel. If the most common medications used on a unit are stocked in the Pyxis machine, nurses won’t have to rely on pharmacy staff to get them the drugs. Not only will a handoff be avoided, but time will be saved as well. Encourage your supervisors to monitor which medications are being used most and design a way to have those drugs available from Pyxis.
Improve access to information. Errors are often made when people don’t have enough information. Nurses aren’t expected to know every bit of minutia about every drug, so resources such as a medication information database or a pharmacist should be available when questions arise. Whenever possible, make sure you know the patient’s allergies before any medications are given. Computerized records hold promise for improvement in this area, if they are used correctly.
Policies and procedures must be followed to ensure patient safety. Always take the time to input a person’s allergy information. Also document the reaction to the allergy. Did the patient develop hives? Or did the patient feel nauseated? Many patients interpret side effects of medications as allergies, and documenting the reaction may help pharmacists and physicians prescribe the best drugs for a patient’s condition.
Many other areas can be explored to decrease errors. References are available for those wishing to investigate the topic in more depth.
Because medication errors occur far too frequently in the United States, it is very important to develop a systems approach in dealing with errors. Punishing healthcare professionals for making mistakes that anyone could make is not effective when nothing is done to analyze why the error happened in the first place. Nurses, like all healthcare workers, carry out their jobs in a demanding and challenging environment. Therefore, it is vital for institutions and individuals alike to share a culture of safety that encourages the reporting of errors. Institutions should promote a culture that encourages the prevention of errors rather than focusing on faulting the person who committed the mistake. We will all sleep better when they do.
Aaron Pié is a PharmD candidate at the University of Arizona in Tucson, class of 2009. Terri L. Warholak, PhD, RPh, is an assistant professor for the department of pharmacy practice & science at the University of Arizona’s College of Pharmacy-Pulido Center.
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