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Frequent problems with medication systems noted during ISMP hospital evaluations Part 2

From the June 17, 1998 issue

ISMP is often called upon to assist health care organizations by performing a systems analysis of the medication administration process. In our June 3, 1998 issue we listed five of the ten most frequently occurring problems noted during these visits. In part 2, we list the five remaining problems in the system elements evaluated during these visits. Recommendations for improvement are also given.

Drug Device Acquisition, Use and Monitoring: There is frequently no independent check system for verifying dose and rate settings on PCA pumps. The second most frequent cause of serious errors during drug administration is the misuse of infusion pumps and other parenteral device systems.2 The settings on PCA pumps often default to a standard concentration, requiring the operator to change the setting if a non-standard concentration is used. Even with expertise in the proper use of drug delivery devices, serious dosing errors are often associated with improper flow rate settings. PCA pump settings should be set by one individual, independently checked by another before administration, then documented.

Environmental Stressors: Staff transcribing orders are consistently exposed to noise, interruptions and non-stop unit activity. The process of transcribing orders is particularly vulnerable to distractions in the environment, as unit secretaries or pharmacy personnel are frequently answering telephones and other requests for information while performing order transcription or computer order entry. A study confirms that simple slips due to distractions are responsible for almost three quarters of all such errors.2 Minimize these distractions creatively (overlapping coverage during peak times, division of job responsibilities, encouraging fax or e-mail instead of calls to pharmacy, etc.) to help staff remain focused on order transcription.

Competency and Staff Education: Many practitioners have limited awareness of well known error prone situations reported within their own organization or published in professional literature. Without this information, staff are likely to make similar errors; with this information, staff can assist the organization in identifying ways to prevent similar errors from occurring or recurring. Upon hire (or joining the medical staff) and regularly thereafter, provide staff with updated information about errors that have occurred both within the organization as well as those occurring elsewhere. Develop a test that includes questions addressing problem prone areas such as morphine and insulin dosing, or cross allergenic medications such as Toradol® and aspirin. Require a score of 100% (any incorrect answers should be discussed with staff until it is assured that they understand the correct answer).

Patient Education: Pharmacy staff is not routinely involved in direct patient education. Medication use is a multidisciplinary process which includes patient education. Each discipline adds a specific focus to this education process, reinforcing the information necessary for patients to prevent an error while hospitalized and to safely self-administer medications at home. Begin by implementing automatic educational consultations to pharmacists when patients are receiving certain classes of medications or being discharged on more than five medications. Increased clinical presence of pharmacists on patient care units will allow the necessary time to provide this valuable service.

Quality Processes and Risk Management: Many organizations attempt to compare their error rates with other organizations for the perceived purpose of "benchmarking." These rates are usually based solely on spontaneous voluntary reporting programs that are influenced by how the organization handles employees who make and report errors. Thus, there is much variability between the methods used to detect and report errors in different organizations. Consequently, there is no accurate "national error rate," and arbitrarily determining an "acceptable error rate" leads to complacency with a dramatic slowdown on prevention efforts. In addition, the term "benchmarking" is erroneously used when organizations attempt to compare error rates. In reality, benchmarking is a process of identifying the best practices through a consistent and accurate method of measuring outcomes while determining the practices that lead to these outcomes. Comparing error rates without an understanding of the processes and systems behind the numbers serves no useful purpose. Spend time more constructively by focusing error prevention efforts on the use of high alert drugs that have the capacity to seriously harm patients if misused.

References: 1. Lesar TS et al. Factors related to errors in medication prescribing. JAMA 1997:277:312-317; 2. Leape LL et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43.

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