No mistake about it: Speaking up saves lives

Learning to speak up—it’s a simple concept that researchers say could dramatically reduce the number of healthcare errors. In fact, so many more workers are challenging authority and reporting their mistakes that the increase in the reported number of errors could be misleading, said Hedy Cohen, RN, vice president of nursing for the Institute for Safe Medication Practices (ISMP) in Warminster, Penn.

Every year, 120,000 patients die and another 1 million are harmed through medical error. When that statistic was announced at a recent conference on examining errors in health care, it “blew away the room” of 300 healthcare professionals, said Arline Gerard, RN. She considers the subject so important that she paid her own way to attend the conference at the Annenberg Center for Health Sciences at Eisenhower Memorial Hospital in Rancho Mirage, Calif.

Common causes of medication errors

Lookalike packaging and labeling
About 53 percent of reports of medication errors received through the Medication Errors Reporting Program relate to similar labeling and packaging for different products.

Soundalike drug names
There are more than 645 pairs of lookalike/soundalike drug names. Of the medication errors reported, 22 percent involve actual or potential errors due to similar drug names.

Illegible handwriting
Prescribers’ scrawl has resulted in misinterpretation and incorrect transcription of written medication orders. These account for 15 percent of reported errors.

Abbreviations
Using an abbreviation for a drug name or directions can lead to a patient receiving the wrong dose. About 4 percent of reports involve abbreviations.

SOURCE: U.S. Pharmacopeia

The conference was groundbreaking because it is the first broad-based, multidisciplinary look at errors in general, according to Deborah Runkle, senior program associate for the American Association for the Advancement of Science. The association sponsored the mid-October conference with the American Medical Association (AMA), the Joint Commission on Accreditation of Healthcare Organizations, and the Annenberg Center.

The conference’s multidisciplinary approach extended beyond healthcare professionals. Keynote speakers included a pilot from the Federal Aviation Administration and an investigator of the space shuttle Challenger disaster, who spoke about the serious need to break the chain of command to avert tragedy. Eight to 10 workers knew the space shuttle shouldn’t launch, but they were junior employees who didn’t voice their message to the people in authority.

“It was everybody’s fault. They were set up to fail. It was a systems problem,” said Gerard, an allergy nurse at Kaiser Permanente Garden Grove, Calif. “The aim for this conference was for people to be able to look at things and say, ‘We need to fix this.’ ”

The conference emphasized looking at systems rather than individuals when analyzing how to prevent errors. “Without exception, nobody is not careful,” Runkle said. “It’s as close to 100 percent as it will be. We have got to bring in new areas of expertise and new ways of approaching problems. There is a challenge for doctors to say others have expertise. The solution has to involve going beyond and overcoming the strong culture of hierarchical tradition and reaching out and learning from the non-healthcare professions.”

“In the old paradigm there was right and wrong and black and white, kind of punitive behavior,” said Marjorie Beyers, PhD, RN, FAAN, executive director of the American Organization of Nurse Executives, who spoke on a panel whose theme was “The Challenge Before Us.”

“Now, I think the whole tenor of our world is continuous improvement,” Beyers said. “People are coming forward and looking for ways to improve much more openly. We acknowledge there are errors and it does happen. The point is, to learn what happens, then find out how to change it.”

At the conference, the AMA announced the creation of the National Safety Foundation, a clearinghouse for information, education, and research for the improvement of patient safety. The foundation is expected to be established by January. One of its main functions will be to raise money for research to design systems that will make it more difficult for human error to occur.

“Some of the other industries, like aviation, are more advanced than medicine has been in recognizing that the human actors aren’t perfect and there need to be mechanisms in place,” an AMA spokesperson said. “They have done a good job in encouraging people to share information. We want to set up systems to facilitate that.”

More people are learning to speak up once errors have occurred. Spokespeople for the ISMP and the U.S. Pharmacopeia (USP) Medication Errors Reporting Program noted an increase in reporting. “People are more interested in learning about what they can do,” said Shawn Becker, manager of program development for the USP practitioner reporting program in Rockville, Md. The ISMP is a nonprofit organization that provides independent practitioner review of medication error reports submitted to the USP program.

The USP also has a new advisory panel on medication errors made up of nurses, pharmacists, and physicians that met for the first time in July. The National Coordinating Council for Medication Error Reporting and Prevention targeted prescriptions as the first step toward ensuring what have been called “the five rights”: the right drug in the right dose by the right route to the right patient at the right time.

Problems with prescriptions account for about 15 percent of the medication error reports received by the program. While illegible handwriting on prescriptions and medication orders is the most widely recognized cause of medication errors, other problems include the absence of leading zeros and the presence of trailing zeros, misinterpreted abbreviations, and incomplete medication orders.

One of the council’s recommendations to reduce these errors is for prescribers to use a direct, computerized order-entry system. Others include adding a brief note about the medication’s purpose, including the age and weight of the patient on the prescription or medication order, and writing out the drug name, exact metric weight, or concentration and dosage form. When writing amounts, the council recommends always using a leading zero before a decimal fraction (0.1 instead of just .1) but never using a trailing zero after a decimal, which might lead to a tenfold error in drug strength. (For example, 0.20 could be read as 2.0).

Compared with two years ago, many more people are trying to identify the underlying systems errors associated with medication errors, said Lucinda Maine, PhD, a pharmacist and senior vice president for professional affairs for the American Pharmaceutical Association (APhA) in Washington, D.C.

Error-prone drugs

More than one-third of all medication errors involve just six categories, according to a preliminary study the Institute for Safe Medication Practices completed in July. Of the 156 hospitals that participated in the study, 20 percent reported no serious errors.

Problem categories are:

Allergy medications

Insulin

Heparin

Opiates

Patient-controlled analgesia devices

Potassium concentrates

Pharmacists are encouraging patients to be informed medication consumers. An APhA telephone survey of 1,000 senior citizens showed that up to 90 percent of new prescriptions now come with some descriptive information. As recently as three years ago, this was not the case, Maine said.

A bare majority, 51 percent, said they had direct contact with a pharmacist, while 30 percent said they would like to have more access. The APhA has been pushing for more direct interaction between pharmacists and patients for some time, Maine said.

“There truly is a movement afoot to redirect the pharmacist’s time to value-added service,” said Maine, referring to the possible benefits to the patient when the pharmacist explains the dosage and side effects of a medication. “From my own perspective, the patient is their own best therapist. They can’t do it by themselves, but they need to become educated. It’s underemphasized today.”

Conference speakers stressed the need to move beyond the “blame and shame” model of health care, which discourages a care provider from reporting a mistake. To develop an environment that encourages the reporting of errors, the worry about blame needs to be taken out of the equation, Runkle said.

“The nurse is usually the last person who handles medication. In reality, the error might have started with the doctor’s handwriting,” said Cohen, whose group would like to see a “safety net” that would encourage more questioning of medication orders.

Not enough attention is being paid to errors that occur in nonhospital settings, because the data is harder to come by, conference attendees acknowledged. “It’s hard to know how many prescriptions are being filled wrong,” Cohen said. “It’s the doctor writing the prescription in the doctor’s office, being filled by a pharmacist in neighborhood pharmacy. Particularly, they don’t have your record.”

Gathering information is what attending the conference was all about for Gerard. “I kind of went with the idea of getting more ammunition” on preventing errors in health care, Gerard said. “I came away knowing there is nothing out there that is going to keep me from attempting to make a difference.”

To report medication errors anonymously to the USP Medication Errors Reporting Program, call (800) 233-7767.

To order a lecture series titled “Understanding and Preventing Medication Errors,” based on data from the USP Medication Errors Reporting Program, call (800) 877-6733. The series costs $399 plus postage.

To subscribe to the biweekly fax newsletter published by the Institute for Safe Medication Practices that tracks the latest errors in health care, call (215) 956-9181. The newsletter costs $125 a year.