The Truth About Medication Errors
Eliminating medication errors is a goal for all health care organizations, but the path to this outcome is not always clear. Medication errors are often complex and rooted in systemic gaps. We interviewed medication management expert Jeannell Mansur about this multi-layered topic.
1: In your experience, where are medication gaps most likely to occur?
Jeannell Mansur, RPh, PharmD, FASHP, FSMSO, CJCP: I’d encourage professionals looking to locate some potential risk points in their medication processes to think about a couple of things. First, what are the highest risk medication processes that are taking place in your organization? Are those processes structured to reduce risk, as much as possible, through design? For example, consider areas like preparing and ordering chemotherapy, prescribing and preparing pediatric medications, and the sterile compounding of IVs.
High alert medications are also important areas of focus, due to their potential to cause harm if given in error. Strategies to improve safety for these medications should be individualized to each category of medication, and should be designed to address the specific risks of that category.
Another high alert area is the implementation and use of medication-related technology. Health care organizations make significant capital expenditures on technology with goals of improving patient care and improving efficiencies. Health care organizations should take the opportunity to evaluate the performance of these technologies, especially after go-live, to identify and act on opportunities for improvement.
Errors associated with look-alike sound-alike (LASA) medications can also frequently factor into medication gaps. Many medications have names that sound or look similar. Hydroxyzine and hydralazine are a perfect example of two medications with very different purposes whose names sound very similar. Packaging can also contribute to LASA medication mix-ups. The selection, storage, and prescription of LASA medications can all lead to medication errors.
Examine your whole medication management process.
2: How can you evaluate the performance of your medication system?
JM: When looking to evaluate your organization’s performance, it is important to understand that the medication system goes beyond the pharmacy. With the figure above as a reference, think of all the activities that occur in each of the areas that are part of the medication system. Ask yourself what the key performance measures for activities in each area are. With storage, it might be ensuring that medications are secure, or that medication refrigerators are monitored and steps have been taken to protect medications when temperatures are out of range. By using this type of exercise for each of the areas, you will be able to identify important activities and measures that help you to understand how well your medication system is performing.
3: How can I mitigate some of these risk points?
JM: With regards to the LASA drugs we discussed earlier, there are a few relatively simple things organizations can do that would reduce the risk of medication errors. I recommend that organizations utilize tall man lettering when labeling LASA drugs. Tall man lettering capitalizes the parts of the names that are different. For example: “hyDROXYzine” and “hyDRALAzine.” Additionally, some organizations do not organize drugs alphabetically, instead choosing to keep LASA drugs on different shelves, or even in different cabinets altogether. Prescription errors are easier to circumvent when the drugs are entered into databases using both their generic and brand names. These changes may seem simple, but they are a few important ways to help reduce medication errors in your organization.
Many organizations need to drill down to find the true cause of medication errors and gaps. For example, disciplinary action directed at a nurse who accidentally administered the wrong drug to a patient will not necessarily prevent this error from happening again. Taking the time to analyze the error and looking for the root cause will. Examine your entire medication process and find where the gaps have occurred. Once you fully understand how the patient came to harm – where in the continuum of care your processes failed – then educate staff and physicians in order to prevent a repeat incident.
4: Can anything good come from medication errors?
Medication errors are an opportunity to learn about where your organization’s medication system is breaking down, and an opportunity to work on fixing it. While we certainly don’t want medication errors to occur, we want those that occur to be reported so that we can learn from them. Low reporting rates may occur when staff do not feel safe or comfortable in reporting errors and near-misses. Explore why reporting is low, and also examine and understand systematic reasons for errors. Don’t just focus on the individuals who made the error. Ensure that you are helping to implement a culture of safety in your organization. In fact, medication error reporting is a diagnostic of high reliability health care and of your organization’s culture. If staff and physicians in your organization feel comfortable and safe, medication errors will be reported, and this leads to greater quality of care for your patients.
(JCI) If you are interested in bringing a medication management expert into your organization or learning more about medication safety, visit our medication management page. To learn more about Jeannell Mansur, visit her biography page.