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Medication errors: Managing the risk

May 1, 2008
by Jan Bennet, RN, NHA, C-NE
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Along with standard facility procedures for administration, nursing staff should be clear on when and how to withhold medication, crush and/or mix medication with another substance such as applesauce, administer A.C. (before meals) and P.C. medications (after meals), and notify nursing management and the physician. Environmental factors such as lighting, heat, noise, and interruptions that can distract nurses during medication administration should be evaluated as to their impact on safety. Other factors to consider include the appropriateness of drug labeling and storage and staff competency in the administration of medication via routes that are not commonly utilized in the facility (i.e., injections, intravenous, etc.).

Reporting medication errors

The organization's mechanism for reporting medication errors is critical to making errors visible when they do occur. Nursing staff must feel comfortable bringing errors to the attention of facility management and understand that reporting is essential to resident safety. This “owning up” and taking responsibility for a mistake is best fostered in an organizational culture that relies on a systems approach to quality improvement rather than blaming individuals. Errors should be reported as soon as they are recognized so that the immediate needs of the resident can be addressed. The policy and procedures should clearly delineate how and when to report errors and establish step-by-step instructions for responding to adverse events.

Periodically conducting medication pass observation can also make errors or the potential for errors visible. Using a procedure similar to the one used during the survey process may increase the comfort level of staff being observed. Consider conducting medication pass observation with nurses who were recently hired, those who have a pattern of medication errors, and those who have difficulty completing the medication pass in a timely manner or who finish too quickly. It is also prudent to regularly observe the administration of medications that have a high potential for error or are delivered via a route that is not routinely used in the facility. Information obtained from medication pass observation cannot only be used to improve individual employee performance, but may also provide insight into procedural areas in need of process improvement.

Another way to identify potential errors or concerns is to routinely conduct focused medical record reviews targeting medication administration records, physician's orders, and other pertinent resident information such as diagnoses, lab results, and changes in condition. Pharmacy consultants can be a powerful ally in the fight against medication errors. Their findings from resident record reviews frequently encompass concerns related to improper indications for drug use, excessive dosage, excessive duration of treatment, drug-to-drug interactions, duplication of medications or side effects, and under-treatment. Every organization should have a process in place to review and act upon these recommendations. Comparing drug labels to actual physician's orders and medication administration records can also identify discrepancies that can contribute to medication errors.

When an error is made

Sometimes, in spite of an organization's best efforts to prevent medication errors, unexpected and adverse events occur. For that reason, it is essential to have effective preparation and prompt response plans at the ready. When adverse events occur, it is important for the facility to first respond to urgent medical needs and take quick steps to protect those involved from further harm. Other actions will include notification of necessary parties, gathering the facts by completing an intensive investigation or root cause analysis, and implementing prompt interventions to reduce the risk for recurrence. Once the immediate needs of the resident have been addressed, legal counsel should be consulted regarding organizational liability and disclosure. How and what is disclosed regarding the incident should be carefully considered in this litigious environment. Facility staff should be cautious regarding the admission of guilt and the full release of documents related to the investigation. Depending on the state, certain aspects of the investigation may be protected under Quality Assessment and Assurance provisions. Communicating with residents and families regarding the error also requires skill. Residents and families are less likely to focus on blame when adverse events do occur if there has been effective communication and there are strong relationships with facility staff. In fact, several studies have shown that the quality of communication plays a primary role in whether families sue following an injury and that certain communication behaviors are associated with fewer malpractice claims.

Jan Bennet, RN, NHA, C-NE, is the Executive Vice President of the American Association of Nurse Executives (AANEX).

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