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Four-pronged error analysis is "best practice"


From the September 22, 1999 issue

To be successful, medication error reduction efforts must result in system improvements that are identified through a four-pronged analysis of errors. The first two prongs, both reactive in nature, include analysis of facility-specific errors that have caused some degree of patient harm and analysis of aggregate medication error data (e.g., trends by drugs or location of drugs involved in errors). Equally important, the other two prongs, both proactive in nature, include analysis of "near misses" (errors that have the potential to cause patient harm) and analysis of errors that have occurred in other organizations. Each prong contains valuable information about weaknesses in the system which, collectively, can lead to effective error reduction strategies. Yet, many organizations focus primarily on the first two prongs of error analysis and action. Most often, proactive efforts are not given high priority. As a result, organizations may be busy "fighting fires" rather than preventing them.

A "near miss" should be clear evidence that a tragic event could occur. Yet, too often, this wake-up call is barely heard. Little attention is focused on thorough analysis of errors that, fortuitously, do not cause actual patient harm, especially if organizations identify errors that require analysis by a severity rating that is based on actual patient outcome. For example, a serious overdose detected before administration may not be given the same priority and analysis as a similar error that actually reached and harmed the patient. Worse, some organizations fail to use errors that have occurred elsewhere as a road map for improvement in their own organization. Sadly, recommendations for system- based improvements, often made by those faced with unraveling a devastating error, go unheeded by others. Even some well-respected health care advisory organizations fail to recognize and promote the power of learning from errors that have happened elsewhere. For example, a recent presentation by The Advisory Board Company, entitled Prescription for Change, failed to promote external error analysis and action as a "best practice" for preventing adverse drug events.

Using external errors as a lens to examine systems in your own organization leads to proactive error reduction strategies, promotion of a non-punitive environment, and clearer understanding of the system-based causes of errors. First, the process encourages open communication about medication errors. Certainly, staff will be more comfortable discussing a serious external error than one that has occurred within their organization. Since blame is not an issue, defensive posturing and other obstacles to effective discussion will not be present. Staff can more easily identify possible system-based causes of the error, the likelihood of a similar error in their facility, and suggestions for improvement. As improvements are made, enthusiasm builds for identifying, reporting, and analyzing errors that are actually occurring within the organization. In the end, discussion about external errors leads to more effective analysis of internal errors.

In our February 25, 1998, issue, we suggested a New Year's resolution to seek and use information about external errors. Shortly thereafter, we began publishing the Action Agenda for committee review and action. While our 1998 subscriber's satisfaction survey revealed that most respondents had implemented at least two error prevention strategies recommended in the ISMP Medication Safety Alert!, it also revealed that distribution of the newsletter to frontline practitioners is not widespread. Please take a moment to complete the survey on page three to help us identify strategies to further promote external error analysis and action, the fourth prong of analysis that is integral to reducing medication errors.

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