Accreditation Resource Services Newsletter
December 2020

CIHQ-ARS Blog

You Want More Medication Error Reports - Really??

By: Gina Miller
"Too err is human....but to persevere in error is only the act of a fool" - Cicero
Most hospitals would be hard-pressed to admit that they would prefer that their medication error rate increase rather than decrease. However, that is exactly what will happen in a well-designed, non-punitive approach to errors. It is very difficult to change a process if you are not aware that the process is broken. To successfully prevent errors, you must be aware that they are occurring, and where in the process the error occurs. The first step to preventing an error is developing awareness.
Developing a non-punitive approach to error reporting is vital to opening communication and promoting organizational high-reliability. Punitive approaches such as issuing warnings or write-ups for errors prevents hospitals from getting a true sense of what the error rate is. Empowering employees to report errors is an important first step to improvements. Common factors that contribute to lower rates of reporting include:
  • No clear definition of what constitutes an error
  • Time-consuming, complex reporting process
  • Fear of repercussions; punishment or ridicule, or being ‘written-up’
  • Not wanting to ‘snitch’ on a co-worker
  • Concern of increasing the medication error rate (in the unit, in the hospital)
Building trust, breaking down the barriers, and creating a culture that encourages error reporting rather than hiding is step one. A hospital in Ohio saw an 80% drop in serious errors after error reporting was encouraged by offering a thank you and coupon to the gift shop. Error reporting increased from 15/month to 70-80/ month, however the increased reporting allowed the hospital to identify several system flaws that contributed to multiple, harmful errors.
Changing the culture encourages staff to be more observant; they will look for potential system flaws or near misses. The safest, most reliable systems are built by anticipating failure and preparing for it and is a key to improving healthcare. Do not be fooled – just because you receive more error reports, the quality of care is not necessarily decreasing. The opposite may be true - staff become more aware and alert to potential errors and identify harm events prior to occurring. It is important to note that a non-punitive environment does not free staff from responsibility in all cases – deliberate or malicious acts should be handled appropriately.
Increased reporting of errors and near misses may require additional time to compile and review occurrences. A multidisciplinary team is helpful to identify the different parts of the process. It is important to remember that error does not equal “harm”. Errors should be categorized using a classification tool such as the NCC MERP. Successful analysis will focus on the multiple components within an error that contribute to system failure vs. human failure. A proactive approach would be to seek out and use information from credible sources (TJC, ISMP, patient safety organizations, etc.) of medication safety risks and errors that have occurred in other organizations to evaluate risks present in your own organization. While you may think it cannot happen in your organization, most likely it can or has already. Some of the most common causes of errors include communication failures (especially during verbal or telephone orders), electronic health record usability issues and workarounds, and look-alike labeling of medications or a combination of several of these.
You cannot decrease errors or adverse events just by identifying them. An easy analogy: you cannot lose weight by getting on a scale every day. You must implement change. Humans make errors and a process that involves people is prone to error. Therefore, if errors cannot be engineered out of the system, processes must be put in place to prevent serious medication events. Failure Modes Effect Analysis is one such tool to evaluate potential failures in your medication process and help identify where and how it might fail, and to assess as well as evaluate processes that are most in need of change. Use of bar-coding, smart infusion pumps, single-use medication packages, and minimizing interruptions to the medication process are all interventions that help eliminate errors. Remember to incorporate medication errors, analysis, and actions taken into your QAPI program.
Lastly, frequently share a review of medication errors and adverse events with staff, along with any changes that are made to minimize their occurrence. This is one of the most important ways to gain staff support. Improvement in medication safety starts with understanding your own medication safety problems and focusing on weak spots. Monitor new actions or system changes periodically to ensure they are still being implemented and achieving the desired risk reduction. Yes, to err is human, but knowing the cause of the error is the beginning of change. Real progress is demonstrated not by the number of new safety initiatives, it is a reduction in actual harm events – tracked over time – to show meaningful progress.

References

Blevens, S. (2020). Medication education: Preparing the patient for discharge. MedSurg Nursing, 29(3), 213-214.
Center for Improvement in Healthcare Quality. (2020). Accreditation standards for acute care.
Center for Medicare and Medicaid Services. (2020). State operations manual appendix A – Survey protocol, regulations and interpretive guidelines for hospitals.
The Joint Commission. (2020). Comprehensive accreditation manual for hospitals, e-edition.
Network for Excellence in Health Innovation. (2012). Improving medication adherence and reducing readmissions: A NEHI issue brief
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