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.