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Nursing Management:
doi: 10.1097/01.NUMA.0000388596.42108.1f
Pharmacy Solutions Extra: Supported by the Institute for Healthcare Improvement

An overview of error‐reduction options

Federico, Frank RPh

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Frank Federico is executive director of strategic partnering at the Institute for Healthcare Improvement, Cambridge, Mass.

Medication errors are the most common errors in healthcare, most likely due to the number of doses administered and the complexity of the medication system. The IOM report released in 2006, Preventing Medication Errors: Quality Chasm Series, found that 1.5 million patients are injured every year from medication errors. According to studies included in the report, 400,000 preventable drug-related injuries occur each year in hospitals. Patients in a hospital experience at least one medication error daily. These errors are common at every stage of the medication process: prescribing, dispensing, and administration. The IOM report goes on to say that computerized prescriber order entry (CPOE) and other IT solutions can go a long way to reduce medication errors.

In February 2009, the federal government passed the Health Information Technology for Economic and Clinical Health Act (HITECH), to stimulate adoption of technology to improve patient safety. This act authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use electronic health records (EHRs) privately and securely to achieve specified improvements in care delivery. Recently, the Secretary of Health and Human Services clarified the objectives of HITECH to include such things as requiring implementing drug-drug and drug-allergy interaction checks and performing medication reconciliation between care settings. This is an opportunity to take advantage of technology to assist in improving quality and reducing errors.

It's no surprise that when nurses are interrupted in the medication administration process, there's an increase in medication errors. Researchers in Australia observed a 25% rate of potentially injury-causing “clinical errors,” like giving a patient the wrong drug, an incorrect dosage, or an improper formulation of a prescribed medication.1 Even when clinicians aren't interrupted, there are opportunities for errors because of look-alike packaging or names, unfamiliarity with medication packaging, and multi-tasking.

A common response is to turn to technology. The danger is the magical thinking that goes along with technology. We must be careful, as technology can introduce a different set of problems and a false sense of safety. Although technology offers many opportunities, there are some low-tech approaches to minimize medication administration errors. The most common are the use of protocols on how to properly administer medications, and vests or sashes that indicate that the nurse shouldn't be interrupted.2

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CPOE

Preventing medication errors starts with providing the correct medication at the appropriate dose. CPOE systems with clinical decision support are an effective way to bring the information to the prescriber at the time he/she needs it. CPOE prompts can guide the prescriber into the correct dose based on laboratory results, alert the prescriber if there's a known allergy to the medication, suggest a formulary alternative, and signal therapeutic duplication and drug interactions.

Several studies have questioned the value of CPOE. A recent report by the LEAPFROG group reported that 214 hospitals tested their order entry systems using a web-based simulation tool to detect medication errors and errors that could lead to serious harm. According to the study, “The CPOE systems on average missed one half of the routine medication orders and a third of the potentially fatal orders.”3

Using the simulation tool, hospitals were able to identify when the CPOE systems didn't provide the appropriate alerts and make needed modifications. On a second attempt, all improved their performance. LEAPFROG asked the federal government to ensure that any meaningful use criteria require monitoring at implementation and on a long-term basis.

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eMAR

The paper-based medication administration record has served to document and remind nurses of doses due. Any paper system is cumbersome, prone to errors, and doesn't include medication error reduction alerts. A well-designed eMAR will support nurses by improving documentation by listing medications administered, doses due, and missed doses. Some systems are designed to include drug information and other activities that are associated with the medications to be administered. The technology facilitates documentation, freeing up nursing time and ensuring that needed information is added to the medical record. The addition of bar code readers and eMAR results in further reduction of errors.

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Remote order review

Recent advances allow pharmacists to review medication orders remotely. The technology is designed to decrease turnaround time. Pharmacists can view orders and enlarge or enhance paper orders for clarity. Pharmacists can be located anywhere, as long as they have access to the technology. After they review orders, pharmacists add the medication to the patient's profile and nurses can access the medication.

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Automated dispensing

Automated dispensing cabinets are computerized medication storage devices that allow for medications to be stored and dispensed close to the point of care. These devices have been in use for some time. Latest technology permits storage in carousels to decrease errors associated with open drawer access. Machines now provide biometric identification, eliminating the use of passwords and accompanying security issues. Machines are interfaced with other databases in the hospital such as the ADT system and pharmacy computers. Alerts can warn a nurse when a medication is removed for a patient with a known allergy to that medication. Other advances incorporate the use of bar code readers to ensure proper filling and removal of medications from the cabinet. Some systems offer alerts reminding staff to remove discontinued medications from the machine to minimize opportunity for errors. The Institute for Safe Medication Practices (ISMP) has developed a Safety Self Assessment for Automated Dispensing Cabinets. Access this tool at http://www.ismp.org/selfassessments/ADC/survey.pdf.

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Bar code medication administration

We're all familiar with bar code technology in supermarkets and big-box stores. New apps for the iPhone include bar code readers. Healthcare has adopted this technology to improve medication safety. Using bar code technology reduces errors associated with wrong patient, wrong drug and dose, and wrong time. The latest bar code technology includes readers that use radio frequency and aren't tethered to a machine. Common bar code is linear and contains the 10-digit National Drug Code (NDC) number that identifies the manufacturer, product, and package size. The 2D symbologies can contain more information, including expiration date and lot number.

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Smart pumps

Calculating infusion rates and programming pumps can be a source of administration errors. In response, industry developed programmable infusion pumps that intercept calculation and programming errors by comparing the dose about to be administered with the recommended dose in the drug library. Improvements in drug library maintenance include the use of radio frequency to update pumps without having to remove the pumps from patient care areas. These pumps provide both soft and hard limits. The former can be overridden and have been associated with medication errors. The latter won't allow the nurse to proceed. Integration of smart pumps with bar code systems will increase the safety of the medication administration process.

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Unit dose/ready-to-administer doses

An old stand-by is a low-tech approach to providing medications in unit dose and ready-to-administer form. Ready-to-administer doses decrease the opportunity for errors associated with nurses preparing medications in areas that aren't designed for that purpose. Pharmacies may repackage materials not available in unit dose or not available with bar codes to increase the safety of the system. National Quality Forum Consensus Standards include the recommendation to dispense medications in unit-dose and in unit-of-use form whenever possible.4

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Radio frequency identification

Radio frequency identification (RFID) is technology that may take hold in the next three to six years as costs decrease. These tags may be used on employee ID tags, patient ID bands and medications, and other supplies. Two types of devices exist: one that's passive and one that's active. The former waits to be read by a device; the latter sends out a signal picked up by another device. At this time, this is an expensive technology. Primary uses have been in inventory control and ensuring the integrity of the chain of custody.

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Electronic medication reconciliation

Medication reconciliation is probably one of the most challenging interventions to improve medication safety. There have been many attempts to link electronically to pharmacy benefits managers and/or primary care offices to collect medication information into a list that can be reviewed. Hospital IT departments and vendors are working to develop applications that facilitate the collection of the list and completion of the other steps of medication reconciliation. Future efforts will include methods to electronically send that information to populate other systems as well as electronic personal health records.

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Serious considerations

Technology effectiveness depends on standardizing processes/doses and concentrations, complete implementation of the technological features, and continuous quality improvement. Implementation of any system requires strong clinical and executive leadership. You must have multidisciplinary involvement, you must consider the entire medication system, and you must understand the present state and agree on the future state. Interfaces with other systems ensure that all vital information is shared and available when needed. Clinical decision alerts will warn nurses only if these interfaces are complete.

When selecting a technology solution, consider the human/machine interface. Is the equipment easy to use? Is the equipment positioned to fit into the nurse workflow or does it force work-arounds?

Technology that incorporates alerts can yield a wealth of information for quality improvement. Data downloaded from smart pumps can be used to determine if there are issues with one staff member, with all staff, or with the doses ordered. Overrides in the automated dispensing cabinets can be used to determine patterns of use and delays in the medication review process. The documentation in an eMAR can help understand why some doses are administered later than scheduled. In each case, the information can be used to drive quality improvement efforts.

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References

1. Westbrook JI, Woods A, Rob MI, Dunsmuir WT, Day RO. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690, 690–692.

2. Agency for Healthcare Research and Quality. Checklists with medication vest or sash reduce distractions during medication administration. http://www.innovations.ahrq.gov/content.aspx?id=1799.

3. The Leapfrog Group. Leapfrog Group report on CPOE evaluation tool results June 2008 to January 2010. http://www.leapfroggroup.org/media/file/CPOEEvaluationToolResultsReport.pdf.

4. National Quality Forum. NQF-Endorsed™ Standards. http://www.qualityforum.org/Measures_List.aspx.

© 2010 by Lippincott Williams & Wilkins, Inc.

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