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Preventing medication errors in the information age

Godshall, Maryann PhD, CCRN, CNE, CPN; Riehl, Mariana BSN, RN

doi: 10.1097/01.NURSE.0000544230.51598.38
Department: PATIENT SAFETY
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Maryann Godshall is an assistant clinical professor at Drexel University in Philadelphia, Pa. Mariana Riehl was a nursing student at Drexel University when this article was written and is now an RN.

The authors have disclosed no financial relationships related to this article.

MEDICATION ERRORS remain prevalent in healthcare. In fact, it's estimated that a hospitalized patient is subject to at least one medication error per day with variation across facilities.1 Adverse drug events, defined as harm experienced by a patient because of exposure to a medication, affect nearly 5% of hospitalized patients.2 According to estimates, 1% to 2% of hospitalized patients are harmed from medication errors, increasing their average length of stay by 4 to 10 days.3

Medication errors can be lethal, with over 7,000 patients estimated to have died each year from preventable mistakes.4 In addition, they cost over $30 billion yearly.5 This article discusses why medication errors still occur at alarming rates despite automated medication delivery systems and bar code technology designed to prevent them.

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Background

The FDA defines a medication error as 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.6 One-third of all medication errors occur during drug administration.3 Most of these happen when a nurse deviates from standard procedures and fails to follow the “five rights” of medication administration: right patient, right drug, right dose, right route, and right time.7 Understanding the fundamental issues associated with administering medications in a hospital setting is key to preventing these mistakes.

Recent data show that almost half of patients transferred from the ICU to a non-ICU location experience a medication error during the transition.8 While most of these errors reached the patients, they tended not to cause significant harm. The three most common errors found were continuation of medication with an ICU-only indication (28%), an indication with no pharmacotherapy (19%), and pharmacotherapy with no indication (12%).8

Further, many errors are not reported at all, due to factors such as a lack of awareness that a mistake occurred, unfamiliarity with the medication administration error reporting process, and fear of personal and legal ramifications. About half of nurses fear disciplinary action for reporting medication errors, and many fear reporting an error could have a negative impact on their performance evaluation.9

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Technology's role

Hospitals have implemented automated dispensing systems and bar code technology to decrease errors and keep an accurate inventory of drugs on the unit. Automated dispensing systems have helped reduce dispensing errors by 31% through packaging and bar coding of medications. Bar coded medication administration systems have been linked to a reduction in medication errors of 54% to 87%.10,11

Many checks are built into these systems. For example, each hospitalized patient wears a bracelet with a bar code that should match the bar code on the patient's medication. The use of on-site pharmacists dispensing medications is also associated with fewer errors.12 This is an easy fix and should be used whenever possible.

One survey of RNs noted that personal neglect, heavy workload, and staff turnover can be major factors influencing the recurrence of medication errors. The survey's authors identified three elements: identification, interruption, and correction.13

  • Identification is the process of knowing the medications, following the five rights, and double-checking the reasons why medications are prescribed. Failure to identify this information contributes to errors.
  • Interruption of nurses as they prepare and administer medications is also problematic. One landmark study found that the frequency of interruptions during medication administration increased the risk of both the number and severity of medication errors.14 Because implementing evidence-based strategies to limit interruptions is imperative, many institutions have taken steps to prevent interruptions during drug administration. For example, areas around the automated medication dispensing machine may be marked with tape on the floor to note that no one is to talk to any nurse working in this designated area. Some facilities have asked their nurses to wear colorful identifying vests or articles of clothing denoting that they are preparing or administering medications and are not to be interrupted.
  • Correction encourages healthcare professionals to understand the number of alerts and warnings of changes in practice standards that a nurse is exposed to daily. Bypassing an alert can lead to a critical error. Note the alert and seek additional clarification or assistance by consulting another nurse, healthcare provider, or pharmacist.14
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High cost of “workarounds”

Automated medication administration systems aren't intended to replace nursing judgment. If a medication bar code scans correctly, some nurses assume it must be right and don't follow the five rights of medication administration. Nurses can also be tempted to take shortcuts—for example, overriding the system if a patient's wristband falls off or is removed and taped to the bed rail, if a medication's bar code doesn't scan after numerous attempts, if the nurse is scanning a medication and receives an error code on the computer screen, or if other similar problems occur. Such workarounds undermine the system's safety features and invite errors. Workarounds result from problems with technology, task, organization, patient issues, or the environment, with these problems often happening simultaneously.15,16 Workarounds indicate functionality issues and a lack of confidence in the system.

A pilot study found that nurses became less satisfied with the medication administration process after bar coding technology was introduced.16 This study differs from previous studies showing nurses were satisfied with the system.17-19 Nurses were initially satisfied with bar coding and open to the change, but frustrations with the system grew as issues arose. In some cases, bar coding devices began to break. Battery charge levels decreased and equipment was not replaced. Over time, the patient's bar coded wristband content wears off, which requires the nurse to print another one to replace the original. In a 2010 study, nurses viewed the system as not “user-friendly” or competent in providing data needed to inform decision-making for medication administration.20 Another study in 2014 using bar coding for immunization administration found improved data quality, but many nurses felt the bar code readability wasn't consistent. Using a particular technique to scan one vial successfully didn't always work with subsequent vials, and nurses had to revert to manually typing in the data.21

Nurses have also had fewer resources and support systems in place to deal with these issues. Staffing ratios have increased, leaving nurses with more patients and less time to report a medication that did not scan. There are also fewer pharmacists available on weekends, so unit-dose medications are not always prepared. The nurse then must reconstitute the medication, calculate the proper dose, and administer it, requiring more time.

The willingness of some nurses to bypass key safety features in the system indicates that they're not fully embracing the technology's ability to significantly reduce medication administration error rates or the technology's functionality is so cumbersome that unacceptable barriers to care delivery occur. Research regarding nursing satisfaction with bar code medication administration systems is limited and conflicting, and needs further investigation.16 From the authors' personal experiences and observation, the system works efficiently most of the time. When it doesn't, nurses tend to become frustrated because of time constraints and use an override or workaround.

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Survey says

The authors conducted an informal survey of nurses to see if they felt automated dispensing systems and bar coding have helped curb medication errors and, perhaps more important, to identify why these technologies have not eliminated these mistakes. Fifty-one nurses from seven hospitals in Pennsylvania answered an informal paper questionnaire on automated dispensing systems and bar coding. Nurses from Florida, Virginia, and Tennessee were also surveyed.

Each nurse felt safe using both the automated dispensing system (ADS) and bar coding technology. Twenty-three nurses felt the ADS had eliminated medication errors while another 30 nurses said bar coding had eliminated errors. Only eight nurses felt that using the ADS hindered the way they work, and six felt that bar coding was hindering. Those who said the ADS is not safe and effective felt it can delay medication administration while the nurse waits for the pharmacy to approve the medication before it appears on the patient's profile.

When asked if they have been personally involved in a medication error, 12 nurses answered that they have been involved in a medication error involving bar code technology. Out of all the nurses surveyed, only one nurse had witnessed the death of a patient due to an issue with the ADS.

The survey also found that workarounds are alarmingly common: All nurses said they overrode at least one warning per shift.

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Future directions

Nurses know the issues highlighted in this article and can offer solutions to the problem. Administrators need to listen to them. Here are some suggestions:

  • Continue tech support after the system is implemented.
  • Have an accessible team of support staff dedicated to solving ongoing problems or issues with the system.
  • Improve maintenance of these computers and handheld scanning devices so nurses don't get frustrated with the technology itself.
  • Maintain adequate staffing of both pharmacists and nurses, especially on weekends and holidays. Being short-staffed leads to shortcuts, which can cause errors.
  • Develop lasting, waterproof bar code bracelets that are less likely to need replacing.
  • Assure that bar codes on medications are not obstructed by any institution-affixed labels.
  • Contact pharmaceutical companies that print bar codes posing readability issues on medications, such as smearing when the vial is handled or becomes wet.
  • Adequately train the pharmacy techs who stock the ADS so the proper medications are placed in the proper pocket/drawer/container.
  • Continue to work with pharmaceutical companies to change lookalike containers. Two medications should not have the same or similar packaging.

Lastly, we need to slow down. Heed the warnings and alerts. They are in place for a reason. Take the time to not only investigate but also call the pharmacy to fix the problem and not leave it for the next shift.

The implementation of unit-based pharmacists directly on the floor in the patient-care areas has been helpful for troubleshooting issues and saving nurses' time. Technology is not perfect. It's only as useful as the person operating it. Every nurse needs to be part of the solution and draw attention to process problems so that we can finally eliminate medication errors.

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