Post on 27-Dec-2015
Patient Safety, Medication Errors, and “At-risk” Behaviors
Christine M. WilsonAdvanced Concepts of PharmacologyViterbo University
Something to Think About
Patient Safety should not be a priority in healthcare.
Medication Error
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
NCC MERP, as cited in Lehne, 2004
Medication Errors Impact Patient Safety
Missed doses Wrong time of administration I.V. rate too fast Wrong concentration or dose
delivered I.V. Wrong route of administration Missed or mistaken provider orders
Nursing Actions ImpactPatient Safety
Mis-identification of patient; wrong medication delivered
Documentation of medications before giving to patient
No documentation of changing patient conditions
Lack of attentiveness Inappropriate judgment
Remember When ? Novice nurse behaviors and actions
Nervous and careful with medication administration
Provides undivided attention to task Prepares one medication at a time Seeks information about unfamiliar meds Checks patient allergies, weight, lab values Has another double check medications Provides education to patient about meds
After Gaining Experience ? Expert nurse behaviors and actions
Prepares IV mixtures, not waiting for pharmacy to prepare
Administers medications before pharmacy reviews orders
“Borrows” another patient’s meds, to allow quick administration
Does not label self-prepared syringes of meds May not take med record to bedside for prns Has unauthorized med “stashes” on unit
At-risk Behaviors Intentional and unsafe practice
habits, learned through experience Healthcare providers, insurers,
pharmaceutical industry, medical device vendors
Engage in at-risk behavior because rewards are often more immediate and positive than the potential for patient harm
ISMP Medication Safety Alert, 2004
Sources for At-Risk Behaviors System-based
Unnecessary process complexity Patient medication in multiple storage areas Nurse may move meds to more readily
accessible area Problems with technology
Repeated waiting for computer terminal access
Physician may resort to verbal orders when prescribing
Pharmacist may skip checking lab values
Sources for At-Risk Behaviors Organizational culture with high tolerance
for at-risk behaviors Staff believes more positive rewards than
negative rewards for at-risk behavior “Saves” time now; chance of patient harm
viewed as remote and unlikely Staff believes more negative rewards than
positive rewards for corresponding safe behavior Labeled as “slow employee”, rather than
“efficient”
Areas Involving Potential At-risk Behaviors
Patient information Drug information Communication Labeling,
packaging Drug stock,
storage, distribution
Patient education
Staff education Technology Environment/
staffing patterns Quality/culture Double checks Teamwork
Environment/Staffing More concern with cost
of medication units, rather than safety
Managing multiple priorities while carrying out complex processes
Failure to adequately supervise/orient staff
Inadequate staffing based on patient acuity
Quality/Culture Sacrificing safety for
timeliness Failure to report and
share med error information
Organizational culture inspires secrecy instead of openness
Finger-pointing rather than system change
Double Check/Teamwork Failure to perform
independent double check thoroughly
Failure to ask colleague to double check medication
Reluctance to consult colleagues for help
Unresponsive to colleague’s request
Consider . . .
Should patient safety be a priority in healthcare? “Priority” implies an order in a list that
can be altered according to circumstances
Could this “order” be based on: Demands of the shift or day? Focus of expedience, productivity,
efficiency, or cost effectiveness?
Case Example
You have had a busy shift and it is now 1400; a new admission has been assigned to you and the patient will arrive soon. Due to family obligations, you must leave the unit at exactly 1500. The 1400 IV medication for one of your other patients is “missing”, so you call the pharmacy.
Discussion
Under these circumstances, how would you react to: Pharmacist takes time to fully investigate
where the missing medication is located Pharmacist immediately mixes another
dose and sends it to you Priorities? Which action offers more positive
reinforcement?
Case Example
It is 0800 and you are engaged in a hectic patient assignment. The physician is writing orders to transfer one of your patients to another nursing unit. The hospital policy states that medication administration records will be reviewed by the physician during the transfer process to avoid unintentional discontinuation of medications.
Discussion
Under these circumstances, how would you react if: You are using the medication administration
record when the physician wants it The physician elects to not check the
medication administration record prior to writing orders
Priorities? Which action offers more positive
reinforcement?
Patient Safety as a Value Link uncompromised patient safety to
every healthcare activity Emphasize specific behaviors which
contribute to patient safety When at-risk behaviors identified:
Do not use disciplinary actions Do uncover reasons for using them Conscious risk-taking not involved in all
medication errors; prompt for answers
References Institute for Safe Medication Practices. (2004, October
7). ISMP medication safety alert! Retrieved April 17, 2005, from http://www.ismp.org/PDF/At_Risk_behaviors.pdf
Institute for Safe Medication Practices. (2004, October 7). Reducing "at-risk” behaviors. Retrieved April 17, 2005, from http://www.ismp.org/MSAarticles/ReducingPrint.htm
Institute for Safe Medication Practices. (2004, September 23). Why we engage in "at-risk behaviors". Retrieved April 17, 2005, from http://www.ismp.org/MSAarticles/PatientPrint.htm
Lehne, R. A. (2004). Adverse drug reactions and medication errors. Pharmacology for Nursing Care (5th ed., pp. 62-71). St. Louis, MO: Saunders.