Mr. Hamilton* had been in the hospital for three days because his blood sugar had suddenly gone out of control. The doctor had adjusted his medication regimen twice since his admission, so when the pills Hamilton was offered looked different, he wasn’t surprised. He mentioned it to the nurse before he took them, triggering her to retrieve the pills and double-check it with the Medical Administration Record. She had inadvertently offered him the medication for the man in the next bed, an antibiotic that would have caused an allergic reaction. Thanking her lucky stars that “nothing happened,” Jackie* went on with her shift. She never reported the “near miss.”

These close calls are typical of the ways that medication errors could occur — as many as 19,500 a year, according to the New Jersey Health Care Quality Institute.¹ For many years, a climate of blame and punishment surrounded medication errors, says Kathleen Ashton, APRN, PhD, clinical associate professor of nursing, department of nursing, Rutgers University-Camden, N.J.

The ‘human factor’

“What was needed,” Ashton says, “was recognition that this is a ‘systems issue’ in that the problem stems from unsafe systems. There needs to be an emphasis on support for the professional reporting the error.” The system has always been geared toward the need for individuals to be vigilant and meticulous. One of the problems is that it denied the human element: People are fallible and apt to err.

Ashton and coauthor Patricia Iyer examined the existing research on medication errors for an article in Nursing Leadership Forum.² They found that most of these mistakes take place because of basic communication problems, some of which can be alleviated by using the latest technology to do an end-run around the “human factor.”

“Many facilities have moved to direct entry of medication orders by the physician into the hospital computer. This avoids problems related to transcribing orders and interpreting illegible handwriting,” Ashton says.

One new approach is the common bar code scanning technology used in grocery stores. The patient’s wristband is coded and all medications ordered have the corresponding bar code. “The nurse scans the medication and then the wristband. If they don’t match, it’s a red flag and can be double-checked,” Ashton says. This built-in safety mechanism allows for the possibility of human error.

Many hospitals are increasing the contact that nurses and pharmacists have with one another, promoting communication. Ashton points out that the more nurses know about the medications they are giving to their patients, the safer the process becomes. This starts at the basic nursing education level, and students in the Rutgers-Camden nursing program are required to be familiar with the medications they are going to give on any clinical day.

There is a general focus in the profession on medication awareness. The National Council Licensure Examination includes medication questions and calculations, so the new graduate is able to make appropriate determinations about the orders and dosages patients are receiving.

Another safety measure hospitals have implemented is reading back verbal orders. “Repeating the order is so important to communication,” Ashton says. “Sometimes, the nurse is confronted with someone who is busy and doesn’t want to take the time for this double-check, but it’s an important improvement to communication.”

Communication problems are not the only pitfalls to medication safety, she says. Similarly named medications, packaging that is difficult to distinguish, and pills that look alike are all potential threats to safety. Patients need the kind of education that can help them protect themselves.

“Some elderly patients think that Digoxin and Lanoxin are two different medications,” Ashton says. “A big part of promoting patient safety involves teaching people to ask questions and commending them when they do. A lot of people are reluctant to ask questions.”

This partnership gives the consumer a role in the process. Ashton points out that many medication errors may never be discovered, and many patients may take incorrect medications at home without realizing it.

Reporting without fear

“In the past, the onus has always been on the nurse making the error,” Ashton says. “People were afraid to admit mistakes because they might lose their jobs. But people make mistakes — they’re people.”

Joining 23 other states, New Jersey has recently passed legislation that establishes rules requiring hospitals to report “serious preventable adverse events” in the facility. Employees are encouraged to report anonymously near misses, preventable events, and incidents not otherwise subject to the mandatory reporting requirements. The goal is to bring to light patterns of care that can be adjusted to improve patient safety.

“We need to ask the question, ‘How can we make it safer?’” Ashton says. “Being aware of these events makes it easier to address changing the system. The question should be ‘How can we redesign things to make it harder to make a mistake?’ We want to prevent issues.”

Hospital employees who report errors are protected by their anonymity, and the facility, in some cases, is shielded from legal discovery when investigating incidents. Other rules of discovery, as in the case of the medical record and other information available to lawyers, would continue unchanged.

The focus of the new law is to try to identify trends and common “weak spots” in the systems that hospitals use to deliver care. Analyzing similar incidents in multiple hospitals would highlight areas that might be adjusted to eliminate common errors. The human factor may never be eliminated, but other factors can be adjusted to make it more difficult to make mistakes.

New Jersey’s Department of Health and Senior Services will receive and analyze the information and use it to issue directives to all hospitals as patterns are identified. Although many hospitals already have reporting mechanisms in place, there is no universal way of tracking trends and making adjustments in the systems for care.

Medications are one of the more multilayered areas of patient care. The primary health care provider initiating the order, the order transcriptionist (nurse or unit clerk), the pharmacist, the charge nurse checking the order, and the nurse actually giving the medication all have a hand in the process. That means many hands pass the information forward, and those hands are attached to people who make mistakes. Removing fear and blame from reporting can help in finding ways to prevent those mistakes.

With this new approach to reporting and dealing with medication delivery systems, Mrs. Dower’s* question about the color of her pill would have led the pharmacist to double-check the medication. With a new “systems management” approach to tracking, Jackie* might have reported her “near miss” and, in doing so, helped identify areas of weakness in the hospital medication delivery system.

By redesigning structures for care to allow for human frailties, patients can be safer, and nurses can be more comfortable and secure that they are giving the best possible care.

*Names have been changed.

Marylisa Kinsley, RN, BSN, is a contributing writer for Nursing Spectrum.

References

1. New Jersey Health Care Quality Institute Website. Available at: www.njhcqi.org. Accessed July 3, 2004.

2. Ashton K, Iyer P. Medication errors, a bitter pill. Nurs Leadership Forum. 2003;7(3):121-128.