The medication errors experienced by actor Dennis Quaid's newborn twins have received a lot of media attention. While hospitalized at Cedars-Sinai Medical Center in Los Angeles last November for treatment of a staph infection, Quaid's twins received a dangerous overdose of heparin. Each baby received 10,000 units of the drug rather than the 10 units they were supposed to receive. Quaid and his wife Kimberly Buffington have sued the maker of the heparin formulation the children received, and are in the process of setting up a foundation to address the problem of hospital errors. Although this experience aimed the spotlight at mistakes made in the hospital setting, medication errors are all too prevalent in long-term care as well.
A drug safety study completed by the Institute of Medicine (IOM) found that medication errors are surprisingly common; approxi- mately 800,000 preventable adverse drug events (ADE) occur each year in long-term care facilities and $887 million is spent annually to treat medication errors that occur in Medicare recipients ages 65 and older.1 A 2005 study published in the American Journal of Medicine, indicated that one out of every 10 nursing home residents suffers a medication-related injury and that 73 percent of the most severe injuries, including internal bleeding and death, was preventable.2
Lawsuits involving drug errors made by nurses are also on the rise. In these cases, the court determines liability based on the standard of care required of nurses when administering drugs. In many instances, if the nurse had known more about the proper dose, administration route, or procedure connected with giving the drug, the mistake that resulted in the lawsuit might have been avoided.3 Because most medication errors occur in the ordering stage, primarily prescription of the wrong dose and failure to recognize drug interactions, it is imperative that the nurse be knowledgeable about the medications that are being administered.1 Because of the serious consequences resulting from medication errors, implementation of effective risk management should be the focus of every facility's quality assessment and assurance program. All processes related to medication administration should be evaluated for safety and prioritized for quality improvement as the need arises. As described by the IOM, designing healthcare processes for safety involves a three-part strategy: (1) designing systems to prevent errors, (2) designing procedures to make errors visible when they do occur, and (3) designing procedures that can mitigate the harm to residents from errors that are not detected or intercepted.4
Preventing errors begins with receipt and review of physician's orders. The American Hospital Association reports that common types of medication errors include the prescription of medication based on incomplete patient information such as not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results. Another common type of error is the result of miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations. The nurses responsible for the review and transcription of a physician's orders must be thorough, reliable, and diligent in analysis and clarification. Having knowledge of a medication's safe dosage limits, potential side effects, toxicity, and indications and contraindications for use are important to the task. Illegible, unclear, or confusing medication orders must be clarified and the physician must be notified when communication is questionable or a discrepancy is identified. The organization's standard abbreviation list should be used consistently by all nurses. If such a list is not available, physician orders should be written out in full to avoid miscommunication. For guidance in establishing a standard abbreviation list, the Joint Commission has issued a “Do Not Use” list of abbreviations that are commonly misinterpreted. (http://www.jointcommission.org/PatientSafety/DoNotUseList/)
The process for administration must also be designed to prevent errors. One approach to safe medication administration is the use of the “six rights”:
the right drug
to the right resident
at the right time
the right dose
by the right route, and
with the right documentation
These principles should be included in the orientation of newly employed nurses and reviewed on a regular basis thereafter. The use of consistent staffing assignments whereby the same nurses are responsible for administering medications to the same residents on a daily basis, can promote a greater understanding of each resident's medication regimen and increase staff awareness of resident response to treatment. All nursing staff should be aware of dangerous drug interactions.
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.).
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.
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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the right drug
to the right resident
at the right time
in the right dose
by the right route, and
with the right documentation