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Medication Errors & Prevention

Medication errors are among the most common medical errors, harming at least 1.5 million people every year.

What are Medication Errors?

A medication error is defined as “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 (1).” 

Medication errors can include (2):

  • Incorrect diagnosis
  • Prescribing errors
  • Dose miscalculations
  • Poor drug distribution practices
  • Failed communication
  • Lack of patient education

The Main Cause of Medication Errors

Understanding the most common risks of unsafe care can help organizations reduce medication errors, while improving patient safety.

Healthcare organizations commonly experience employee underreporting of safety incidents. (3)

According to a study released by the US Department of Health and Human Services (HHS), roughly 86% of patient safety incidents occurring in healthcare organizations go unreported. (3)

During in-depth interviews and focus groups with physicians, pharmacists, and nurses from 4 community hospitals, investigators compiled a list of the most cited barriers to medication error reporting:

  • Extra time required in reporting
  • Cumbersome report forms
  • Hesitancy about “telling” on someone
  • Perceived severity of the error

Medication Error Prevention – A Story from a Nurse

Right out of school, I began my nursing career in the emergency department (ED).  After working for 5 years in the ED, I transferred to the ICU. It was during my orientation of the ICU that I realized the differences between the two areas. The ICU consisted of routine administering of morning medications, providing breakfast, and visiting hours, etc. 

At the time, the hospital was not yet operating on a system for electronic medical records (EMR). One morning during routine medication administration, one of the drugs was not in the patient’s bin.  I contacted the pharmacy for the medication that morning.  About an hour later, I still hadn’t received the medication.  Therefore, I contacted the pharmacy again and stated that I would pick it up, which I did.  After I received the medication, I returned to the patient’s room and administered the drug. 

During noon vitals, the patient’s blood pressure was low, around 90/50.  The patient was not experiencing any visible symptoms. His skin was warm and dry, and he was sitting in a chair, conversing with me and his family.

The medication I picked up from pharmacy was for blood pressure and the patient had had open heart surgery the day before.  It’s not unusual for the surgeons to keep patients’ blood pressure low after surgery. This relieves strain on the heart and allows it to rest. 

I rechecked the patient’s blood pressure again, as well as 30 minutes later, and it remained low.  So, I contacted the physician, who advised me to keep a close eye on the patient. The patient remained stable, and his BP remained unchanged, so the patient was transferred to the telemetry unit without any other concerns.  I finished out my shift for the day and went home.  It wasn’t until that night, or should I say early morning, when I woke from a dead sleep and realized why the patient’s blood pressure was so low. 

When I went to the pharmacy, I picked up 2 pills of the same medication and same strength. What I hadn’t realized was that the pharmacy mistakenly dispensed 2 doses, and I had given the patient both doses that morning. 

Had the facility been utilizing an EMR system at that time, this may not have happened.  If I had brought the medication administration record into the patient’s room and double checked prior to administering the medication, I may have caught that I had 2 doses and not just one. This medication error was never reported.

Improve Reporting, Reduce Medication Errors

There are three recommendations to help with underreporting:

  1. Simplify the incident reporting process by making the process user-friendly and easy to complete.
  2. Improve the channels of communication between senior management and front-link staff, as many participants were frustrated for not receiving feedback from the administration.
  3. Increase awareness and education to help front-line staff better understand the process of incident reporting (how to report and incident, why to report and incident, and how incident reporting data is being used).

When searching for an incident reporting solution to avoid medication errors (and other incidents), make sure to look for a software and company that provides the following:

  1. User-friendly interface and functionality
  2. Takes less than 2 minutes to report and incident
  3. Provides follow-up management tools including a root cause analysis
  4. Dashboards to share among teams, if needed
  5. Diverse education to all team members (videos, how-to’s, access to their team, etc.)

Reduce Medication Errors with Performance Health Partner’s Software

With the high cost and negative patient outcomes associated with medication errors, the importance of prevention is clear. With Performance Health Partner’s Incident Reporting System, healthcare organizations can access the data they need to mend fragmented care delivery systems, while improving overall patient safety.  Learn more at https://www.performancehealthus.com/patient-safety or schedule a demo here. 

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References:

  1. National Coordinating Council for Medication Error Reporting and Prevention
  2. https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors
  3. https://www.medscape.com/viewarticle/756540

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