5 Ways To...

Karen Wagner

About one-third of the more than 100,000 adverse events recorded by ECRI Institute’s patient safety organization are medication errors—with the most common errors occurring in the administration stage. Karen P. Zimmer, MD, MPH, FAAP, medical director for ECRI’s patient safety organization, offers strategies for adopting a system-based approach to preventing errors.

Provide leadership support for the training and resources needed to prevent errors. There are two ways hospital and health system leaders can help to reduce medication errors that occur in the administration stage: Explain to staff why a systemwide medication safety initiative is necessary, and provide resources and training necessary to implement change. When an organization’s leaders explain the importance of the initiative, staff are more likely to accept it and support it with action. “If staff do not understand the importance of an initiative, it will not be sustainable,” Zimmer says. Leaders then should ensure that the organization is investing in the appropriate resources to support the work needed to effect change.

Evaluate medication-administration processes to identify strengths and weaknesses. The organizations should examine breakdowns related to how medications are administered and the environment in which they are administered. A nurse who retrieves multiple medications at the same time risks giving a patient the wrong medication. Nurses should understand that making individual trips to the cabinet for each medication is required. The organization should move beyond the human error to determine what in the nurse’s environment is causing him or her to do the work around.

Use multiple techniques to track medication errors. Common methods for tracking medication errors include event reporting, chart reviews, and direct observation. Another tool is rounds, where senior executives visit patient care floors to engage in meaningful discussions with clinicians and frontline staff to truly understand the issues and challenges related to medication administration. “The key is to make sure you literally walk on every floor of the hospital at least once a month,” says Zimmer, noting that the rounds can be divvied up among leaders.

Involve frontline staff in determining the process changes that should take place. If staff are expected to implement process changes related to medication administration, it is necessary to ensure that these changes make sense to them. “No one has a better understanding of what will work and won’t work in regard to medication process change than frontline clinical staff,” Zimmer says.

Use proactive and reactive risk assessment tools to better understand the barriers to medication safety. An event management analysis should be conducted whether the process breakdown resulted in a medication event or a near miss. “A process breakdown is a process breakdown,” Zimmer says. “A similar breakdown may have occurred in a near miss as it did during an event, but with a near miss, the breakdown never reached the point of harm. Near misses are opportunities to learn where there are breaks in clinical processes, why they were caught before they could cause harm, and how to prevent future events.”


Karen Wagner is a healthcare freelance writer, Forest Lake, Ill., and a member of HFMA’s First Illinois Chapter (klw@klw.ms). 

 

Publication Date: Monday, October 01, 2012

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