Chapter 6- medication errors

General Impact of Errors on Patients

 Institute of Medicine (IOM) 1999 Study:

o Found 44,000–98,000 annual deaths in U.S. hospitals due to medical errors.
 IOM 2006 Study:
o Identified 1.5 million people harmed annually by medical errors, including
117,000 hospitalizations.
o Financial cost: Over $4 billion.
 2010 Follow-Up Study:
o Reported 25.1 "harms" per 100 hospital admissions.
o No significant improvement in preventable error rates since 1999.

Canadian Data on Adverse Events

 2004 Landmark Study:

o Estimated 9,000–24,000 patient deaths annually due to adverse events in
Canadian hospitals.
 2008 Study:
o Found adverse drug-related events responsible for 12% of emergency department
visits, with 68% preventable.
 2009 Study:
o Reported that 17% of Canadian adults (4.2 million) believed they experienced a
medical error in the prior 2 years.
o Key contributing factors:
 Multiple prescriptions.
 Chronic conditions.
 Insufficient time with physicians.

2016 Canadian Institute for Health Information (CIHI) Report

 Found harm occurred in 1 in every 18 hospital stays (138,000 hospitalizations) between

2014–2015.
 Common medication incidents:
o Insulin (9%).
o Hydromorphone hydrochloride (7%).
o Heparin (4%).
 Primary contributing factor to errors:
o Distractions or interruptions during medication administration (27%).

Efforts to Reduce Medical Errors

 Emphasis on error prevention has become a priority in health institutions.

 Shift in Error Reporting Culture:
 o Non-punitive approach to encourage reporting.
o Acknowledgment that reporting can prevent errors.
 Just Culture:
o Recognizes that system faults are the primary cause of errors.
o Holds professionals accountable when policies are ignored or repeated errors
occur.
o Factors such as workplace culture and management behavior may hinder error
reporting.

Types and Locations of Errors

 Errors occur across all phases of health care delivery and among all categories of
providers.
 Common types of medical errors:
o Misdiagnosis.
o Patient misidentification.
o Lack of patient monitoring.
o Wrong-site surgery.
o Medication errors (MEs).
 Errors in home settings:
o Harmful due to potent outpatient drugs.
o Fatal errors often involve mixing prescription drugs with alcohol or other drugs.

Consequences of Medical Errors

 Intangible losses:
o Patient dissatisfaction.
o Loss of trust in the health care system.
 Adverse outcomes:
o Patients may avoid seeking care, leading to worsened health outcomes.

Medication Errors

Adverse Drug Events (ADEs)

 Encompass all clinical problems arising from medication use (see fig 6.1)
 Include:
o Medication Errors (MEs).
o Adverse Drug Reactions (ADRs): reactions that occur with the use of a
particular drug
 Allergic reactions: often predictable.
 Idiosyncratic reactions: usually unpredictable.
Characteristics of Medication Errors (MEs)

 Impact ranges from no significant effect to patient disability or death.

 Identifying, responding to and preventing Mes require an examination of the entire med
use process
o Focus on all people and all steps involve in med use process, including prescriber,
transcriber of the order, nurses, pharmacists and any other ancillary staff involved
o System approach; examine the entire health care system, health care providers
involved and any other factor that has an impact on the error
 Drugs commonly involved in severe MEs:
o Central nervous system drugs.
o Anticoagulants.
o Chemotherapeutic drugs.
 "High-alert" medications:
o Require special care due to their toxic nature. (require special care when
prescribing, dispensing and administering)
o Potential harm is higher, though not necessarily involved in more errors
 See table 6.1 for ISMP high alert meds

Factors Contributing to MEs

 System-based issues are the primary cause, not individual shortcomings.

 Examples of system weaknesses:
o Lack of a "just culture" for nonpunitive error reporting.
o Excessive workloads with insufficient time for staff education.
o Interruptions during medication preparation and administration.
o Poor interdisciplinary communication and collaboration.

Look-Alike, Sound-Alike Drugs

 Similar drug names can lead to serious errors, especially when drugs from different
therapeutic classes are confused. (similar spelling or pronunciation)
  Can result in patient effects that are grossly different from those intended as part of the
drug therapy
 Strategies to reduce confusion:
o Use of TALLman lettering (combination of uppercase and lowercase ) (e.g.,
VinCRIStine/VinBLAStine) to differentiate similar drug names.
o Aimed at optimizing safety throughout the medication-use process.
 This create a mental alert by changing the shape of words that look similar
when seen in uppercase letters only

Error Reporting and Prevention

 Reporting errors is essential for identifying trends and making systemic improvements.
 Hospitals are required to:
o Analyze MEs.
o Implement preventative measures

Nurse's Role in Preventing MEs

o Must take the time to report errors because without reporting, no changes can be made
o When errors are reported, trends can be identified and processes can be changed
to prevent errors from occurring again
Issues Contributing to Errors

Organizational Issues

Medication Process Steps:

o Errors can occur at any stage:

 Procuring.
 Prescribing.
 Transcribing.
 Dispensing.
 Administering.
 Monitoring.
o Major points of error:
 Prescribing errors: Can often be caught by pharmacists or nurses before
administration.
 Administration errors: Second most common after prescribing errors.
 Dispensing errors.
 Transcription errors.

Interdisciplinary Collaboration:

o Strong nurse-pharmacist relationships are critical for preventing MEs.

o Hospital pharmacists:
 Typically available 24/7 in urban areas.
 Serve as valuable resources for drug therapy questions.
o Rural areas:
 May lack consistent pharmacist or physician availability.
 Nurses should work with their agencies to develop policies addressing
potential MEs.

Patient Involvement:

o Advocated as a critical component of patient safety.

o Benefits:
 Better outcomes through active participation and shared decision-making.
 Increased knowledge of illnesses and treatments.
 Ability to advocate for own safety at every health care encounter.
o Organizations promoting patient involvement:
 Safer Healthcare Now
 Canadian Patient Safety Institute
 Patients for Patient Safety Canada (part of WHO and Pan American
Health Organization initiative).

Technological Solutions
o Effective use of technologies such as computerized prescriber order entry and bar coding
of medication packages shown to reduce Mes

Technologies to Reduce MEs:

o Computerized Prescriber Order Entry (CPOE):

 Eliminates handwriting issues.
 Standardizes prescribing functions.
o Bar Coding of Medications:
 Allows nurses to verify medications electronically at the bedside.
o Computerized Screening:
 Used in pharmacies to identify potential drug interactions.

Adoption of Bar Coding Standards:

o 2008: ISMP Canada and Canadian Patient Safety Institute supported standardized
bar coding.
o 2012: Canada adopted GS1 global bar code standards for pharmaceuticals.
o 2010: Limited use of bar code verification in Canada:
 8% of institutional beds.
 33% of dispensing and compounding practices in hospital pharmacies.

Challenges to Implementation:

o High costs of implementing technology:

 Automated drug dispensing cabinets.
 Electronic charting systems.
 Computerized order entry systems.
o Barriers:
 Costs ranging from hundreds of thousands to millions.
 Nursing shortages and workload issues.
 Inadequate education and training in technology use.
 Difficulty mastering complex systems.

o Self-medication by patients (e.g., patient-controlled analgesia) can reduce errors:

 Requires adequate cognitive ability and alertness from patients.

 World Health Organization :

o Provides resources on patient safety concerns and solutions.
o (see Box 6.1).
Educational System Issues and Their Potential Impact on Medication Errors

Obligations for Double-Checking:

o All health care providers must verify medication information before

administration.
o This includes reviewing medication orders and being comfortable with one’s
knowledge about the drug before administering it

Access to Drug Information:

o Numerous drug information guides are available for nurses.

o Institutions increasingly provide electronic resources like Lexicomp or UpToDate
for quick reference at the point of care.

o Safe practice begins with nursing education. Nurses are important to the med
administration process and must demonstrate safe and reliable practice. Teaching
strategies which must emphasize:

 A just culture of safety.

 Confidence-building in students.
 Habits of self-monitoring.
 Common Medication Errors Among Nursing Students:

o Errors often arise from:

 Unusual dosing times.
 Medication administration record issues (e.g., unavailability, failure to
document, or review records).
 Administration of discontinued or held medications.
 Failure to monitor vital signs or laboratory results.
 Misadministration of oral liquids as injections.
 Preparing medications for multiple patients simultaneously.
 Dispensing incorrect doses (e.g., splitting tablets inaccurately)

Medication Errors and Related Sociological Factors

Role of Effective Communication:

o Improved communication within health care teams contributes to better patient

care.

Workplace Bullying:

o An increasing issue among nurses, distinct from horizontal violence.

o Defined by a real or perceived power differential between the initiator and
recipient.

- Factors Contributing to Workplace Bullying:

 Gender dynamics may heighten or promote bullying.

 Leads to job dissatisfaction, decreased staff retention, and health issues.
o Bullying and disruptive behaviors result in:
 Communication breakdown.
 Reduced collaboration among team members (e.g., nurses, physicians).
 Increased risk of medical errors and adverse events, near misses
 Decline in patient care quality.
o Consequences include:
 Recruitment and retention challenges.
 Erosion of personal health and professional well-being of nurses.
 Negative effects on patient safety and health outcomes.
o Communication between prescribers and team members has improved over time.
o Attributed to:
 Progressive medical education with a focus on teamwork.
 Zero tolerance for violence.
 - Progressive approach Canadian Interprofessional Health Collaborative
(CIHC) national interprofessional core competencies into health professional
education and institutions

Preventing, Responding to, Reporting, and Documenting Medication Errors

Preventing Medication Errors

o MEs: Any preventable event that could lead to inappropriate medication use or
harm to a patient.

Major Categories of MEs (According to the Canadian Medication Incident Reporting and
Prevention System, 2011):

o Near Miss or Close Call:

 An event that could result in unwanted consequences but does not.
o No-Harm Event:
 An incident occurs but does not injure the patient.
o ME Causing Harm:
 An incident resulting in patient harm.
o Critical Incident:
 An incident resulting in serious harm.

Strategies to Prevent MEs:

o Systems of Checks and Balances:

 Implement multiple safety measures to prevent errors.
o Legible or Electronic Orders:
 Prescribers should write clear, legible orders or utilize electronic systems.
o Consulting Authoritative Resources:
 Reference pharmacists or reliable drug literature at every stage of
medication administration if concerns arise.
o Triple-Checking Medication Orders:
 Nurses should review medication orders three times before administration.
 Consult authoritative resources for any questions or doubts.
 Faculty members should avoid being the sole resource for students during
clinical training. Safe resource usage should be instilled during education.
o Rights of Medication Administration:
 Follow these consistently to significantly reduce ME likelihood.
Responding to, Reporting, and Documenting Medication Errors

o Nurses are accountable for responding to and reporting MEs, whether committed
by a nursing student or professional nurse.

Immediate actions:

o Patient Assessment:
 Prioritize the patient’s physiological status and safety.
 Address urgent safety issues immediately.
o Report the Error:
 Notify the appropriate prescriber and nursing management (e.g., nurse
manager or supervisor) promptly.
o Patient Monitoring:
 If the patient’s condition deteriorates or close monitoring is needed, ensure
another qualified health care provider remains with the patient while
notifying the prescriber.
o Implement Follow-Up procedures of tests:
 Administer prescribed follow-up procedures, tests, or antidotes as
indicated.

Reporting Medication Errors

 o Follow institutional policies and procedures for error reporting and
documentation.
o Complete all appropriate forms; an incident report or unusual occurrence report
per facility guidelines.

Documentation:

 Use factual, accurate, thorough, and objective language.

 Avoid judgmental terms such as “error.”
 Include:
 Administered medication and dose given
 Specific details of the error (e.g., wrong patient, wrong route,
wrong time).
 Observed changes in patient’s condition (physical and mental
status).
 Notification of the prescriber and implemented follow-up actions.
 Maintain ongoing monitoring and document findings.
o Incident Reports:
 Incident reports are not part of the patient’s chart.
 Do not document in the patient’s chart that an incident report was
completed.
 Forward incident reports to the risk management department for review.
o Anonymity in Reporting:
 Support anonymous reporting to encourage transparency and improve
safety practices.

Internal Reporting Systems:

o Internal error tracking systems generate data to guide policy and procedure
improvements.

External Reporting of Medication Errors

National Reporting Programs:

o Canadian Medication Incident Reporting and Prevention System (CMIRPS):

 Collects and disseminates safety information on MEs.
o Canada Vigilance Program:
 Health Canada’s post-market surveillance program for adverse reaction
reporting.
 Allows voluntary reporting by health care providers and consumers.
o MedEffect:
 Sends updates on health product advisories and recalls.
o ISMP Canada:
 Provides guidance to enhance safety practices.
o Safer Healthcare Now! and Accreditation Canada:
  Offer resources aimed at safety improvements.

Performing Medication Reconciliation

 Medication Reconciliation (MedRec): A formal process to ensure accuracy and safety

in medication management at all points of entry and exit within a healthcare facility.
 Ensures no discrepancies exist between medications taken at home and those prescribed
during hospitalization.

 Best Possible Medication History (BPMH): A systematic, comprehensive review of all

medications a patient is taking.
 The prescriber assesses and determines which medications to continue upon
hospitalization.

Timing of MedRec

 Occurs at:
o Admission
o Transfer from surgery
o Transfer into/out of the ICU
o Discharge

Common Challenges

1. Patient Knowledge Gaps:

o Patients may not know their exact medications (e.g., “blue pill for blood
pressure”).
o Some medications were discontinued prior to admission and often they fail to
provide this information
o Medication lists provided by patients may be outdated or incomplete.
2. Lack of Patient/Family Involvement:
o Excludes vital information, leading to incorrect medication orders.
3. System and Communication Issues:
o Inadequate hospital policies for medication management.
o Poor communication among physicians and other healthcare team members
regarding medication changes or discrepancies.
o Lack of robust systems to verify proper documentation, ordering, and
transcription of medications.

Steps in Medication Reconciliation

1. Verification:
o Collect comprehensive medication information, including prescription drugs,
over-the-counter medications, and natural health products.
 2. Clarification:
o Review collected information to ensure appropriateness of all medications and
dosages.
3. Reconciliation:
o Investigate discrepancies and document communications and changes in
medication orders.

Steps that should be repeated at each stage of health care delivery:

1. Admission
2. Status changes (e.g., critical to stable condition): Specify which medications to
continue or discontinue.
3. Transfers (within or between facilities or teams)
4. Discharge: Provide a complete, updated medication list to the patient or next
healthcare provider while following confidentiality guidelines.

Assessment and education tips for medication reconciliation:

1. Communication with Patients:

o Start with open-ended questions, gradually narrowing to yes/no questions for
specificity.
2. Avoid medical jargon unless the patient is familiar with the terminology.
3. Prompt for Complete Information:
o Encourage patients to recall all medications, including patches, creams, eye drops,
inhalers, injections, natural products, and professional samples.
o If a medication list is provided, make a copy for the patient’s chart.
4. Clarify Unclear Information:
o Consult caregivers or outpatient pharmacists as needed to verify details.
5. Documentation:
o Record all gathered information in the patient’s chart as the first step in the
MedRec process.
6.
o Stress the importance of maintaining an accurate, current medication list.
o Encourage patients to carry a medication list (e.g., wallet card or digital record)
and bring it to every healthcare visit.
o Teach patients to learn medication names and dosages

Other Ethical Issues: Notification of Patients Regarding Errors

 2001 Landmark Article: Published in the Journal of Clinical Outcomes Management, this
article highlighted the ethical and legal importance of full disclosure to patients when
errors occur.
 Recognized as a starting point for understanding the issue of patient notification about
medication errors (MEs).
 o Canadian Patient Safety Institute (CPSI):
o Advocates for a just culture of disclosure.
o Emphasizes honesty and transparency in disclosing errors.
o Apology Legislation:
o Implemented in eight Canadian provinces and one territory.
o Provides statutory protection: Apologies cannot be used in court to establish fault
or liability.
o Accreditation Canada:
o Includes disclosure in its Required Organizational Practice (ROP).
o Requires healthcare organizations to have a formal, transparent policy for
disclosure.
o Ensures support for the patient, family, and healthcare workers.

 The term error is avoided due to the complexity of patient safety incidents.
 Preferred terminology
1. Harmful Incident: An event resulting in harm to the patient (replaces
"preventable adverse drug event").
2. Near Miss: An incident that did not reach the patient and caused no harm.
3. No-Harm Incident: An incident that reached the patient but caused no harm.

 Healthcare organizations provide financial support for reasonable expenses (e.g., travel,
temporary wage loss) related to the disclosure process.
 Support for healthcare providers involved in disclosure proceedings is also
recommended.

Possible Consequences of Medication Errors for Nurses

Medication errors (MEs) can affect not only patients but also healthcare providers, including
nurses and student nurses. These effects include:

1. Emotional Impact:
o Significant patient harm or death can take an emotional toll on the nurse involved.
2. Legal Consequences:
o Nurses may face malpractice litigation with potential financial repercussions.
o Negligence: Defined as “conduct that does not meet a standard of care established
by law” and characterized by inattention or thoughtlessness
o Malpractice: Improper or unethical conduct or unreasonable lack of skill that
results in harm; compensation may be sought. All malpractice involves
negligence.
3. Professional Liability Protection:
o Nurses in publicly funded institutions are typically covered by institutional
liability insurance.
o Many nurses opt for personal malpractice insurance for additional protection.
 oCanadian Nurses Protective Society (CNPS): Established in 1988, not for profit
society provides legal advice, risk management, legal assistance and professional
liability protection to eligible nurses (excluding Quebec).
4. Administrative Responses:
o Responses vary by institution and may include:
 Continuing education or refresher training.
 Disciplinary actions (e.g., suspension, termination).
o Regulatory bodies may counsel or discipline nurses, with severe cases leading to
suspension or revocation of licenses.
5. Student Nurse Accountability:
o Students are responsible for the quality of their clinical work.
o They should consult clinical instructors or experienced staff when in doubt.
o If an error occurs:
 Notify the clinical instructor immediately.
 Additional monitoring or interventions may be required for the patient.
 Prescriber notification may also be necessary.
o Errors can serve as stressful but valuable learning experiences.

Summary

o The increasing complexity of nursing practice also increases the potential for MEs.
o Widely recognized and common causes of errors:
o misunderstanding of abbreviations, illegibility of prescriber handwriting,
miscommunication during verbal or telephone orders, and confusing drug
nomenclature.
o The structure of various organizational, educational, and sociological systems involved in
health care delivery may also contribute directly or indirectly to the occurrence of MEs.
o Understanding these influences can help the nurse take proactive steps to improve these
systems.
o fostering improved communication with other health care team members,
including students, to advocating politically for safer conditions for both patients
and staff.
o The first priority when an error does occur is to protect the patient from further
harm, whenever possible.
o All errors should serve as red flags that warrant further reflection, detailed
analysis, and future preventive actions on the part of nurses, other health
care providers, and possibly even patients themselves.