Near Misses

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Adverse Drug Events

The Institute for Healthcare Improvement (IHI) refers to adverse drug events (ADEs) as injuries attributable to the use of medications (1). Hospitalized patients who experience an ADE are almost twice as likely to die as those without an ADE (2). Death certificate data showed that almost 1,200 hospital deaths in 1993 were due to medication errors. In addition, the incidence of such deaths had more than doubled since 1983 (3). Medication errors are one of the leading causes of injury to hospital patients, and chart reviews reveal that over half of all hospital medication errors occur at the interfaces of care (4). ADEs account for 6.3% of malpractice claims (5). A study of pediatric cancer patients revealed variances between medication orders and information from patient/guardian or prescription labels on the container 30% of the time (6). A multidisciplinary check of medication orders, also for pediatric cancer patients, revealed that 42% of the orders being reviewed needed to be changed (7). According to one estimate, in any given week four out of every five U.S. adults will use prescription medicines, over-the-counter (OTC) drugs, or dietary supplements of some sort, and nearly one-third of adults will take five or more different medications.

Most of the time these medications are beneficial, or at least they cause no harm, but on occasion they do injure the person taking them. At the urging of the Senate Finance Committee, the United States Congress mandated that Centers for Medicare and Medicaid Services sponsor a study by the IOM to address the problem of medication errors. Preventing Medication Errors (8) puts forward a national agenda for reducing medication errors based on estimates of the incidence and cost of such errors and evidence on the efficacy of various prevention strategies.

The report finds that medication errors are surprisingly common and costly to the nation, and it outlines a comprehensive approach to decreasing the prevalence of these errors. This approach will require changes from doctors, nurses, pharmacists, and others in the health care industry, from the Food and Drug Administration (FDA) and other government agencies, from hospitals and other health-care organizations, and from patients.

Despite numerous studies into the causes and management of medication errors, they continue to occur on a daily basis in most healthcare institutions (10). It is commonly assumed that errors occur because of a lack of knowledge and additional in-service education is often implemented following an error. However, one study found that failure to follow the correct procedure was associated with only a small proportion of the errors observed in a large study of over 1000 drug administrations (11). All nurses receive training on this important aspect of their role and if questioned, most if not all, would be able to recite the correct procedure for checking medicines. But, as has been pointed out, "humans will always err, and need assistance in checking procedures to detect mistakes" (12). The literature suggests that other factors such as workload, shift pattern worked, time of day and environmental factors can also contribute to errors (13 ; 14).

Near Misses

Although in the vast majority of cases no significant harm befalls the patient, except perhaps to receive sub-therapeutic treatment, making an error can seriously affect the nurse and his/her clinical confidence. The first feelings of disbelief are rapidly followed by fear for the patient's safety, fear of personal consequences and then feelings of professional failure (15 ).

The American Nurses Association (ANA) has been working to quantify nurses' interventions in preventing errors by capturing information about "near misses." The following nurses' responses are intended to inform their colleagues, hospitals, and others of strategies to make patients safer. The ANA “Near Misses” questionnaire has been submitted anonymously by a number of nurses. Their confidential responses from the fourth quarter of 2005 have been aggregated and information synthesized from the data is presented below.

Issues

Respondents defined patient safety issues that have occurred. Central to those reports is a sense that practitioners are n ot engaging in the “5 Rights” consistently prior to administration of medication. Relying on accuracy of medications in automatic dispensing systems rather than consistently engaging in the 5 rights prior to administration of medication is particularly problematic. There are errors made by individuals at all steps in the medication process (prescribing, transcribing, dispensing and administering) frequently due to a lack of adherence to organizational policies and procedures. However, insufficient numbers of adequately experienced nurses on staff resulting in utilization of “float” nurses; as well as a lack of sufficient support staff to assist nurses in providing safe patient care are repeatedly implicated in medication errors.

There is frequently an incomplete noting of patient allergies. Incorrect utilization of devices, including those designed to be of assistance to patients as well as to administer medications has resulted in harm to patients. Finally, chemotherapeutic agents, look-alike/sound-alike drugs and anti-diabetic agents are of particular relevance in the reports.

Role

Nursing's role in the interventions was highlighted. Registered nurses (RNs) were far and away the discipline most reported as being the individuals who prevented errors. Patients, too, took an active role in preventing error, especially in regards to incorrect oral medications. Licensed Practical/Vocational Nurses ( LP/VNs), serving in the role of medication nurse, were also noted as intervening, particularly in long term care settings. Of particular note was the number of instances in which nursing students intervened to prevent errors from occurring.

Outcome

Fortunately, for the most part, errors were discovered before incorrect medications were administered and patients eventually received the right dose of the right medication . The majority of adverse patient outcomes as described resulted in no long-term effects. Minor effects including itching and rashes. More serious results included skin breakdown. Involved patients were frequently submitted to delays in treatment as well as to additional tests. In addition, hospitalizations were sometimes extended, often in a higher level of care.

Recommendations

Ways in which errors can be avoided were suggested:

  • A system of checks and balances should be employed vis-à-vis medication administration;
  • Part of checks and balances is asking, asking, and asking again;
  • Adequate numbers of appropriately qualified staff are critical;
  • Engaging the patient and family in the process of care;
  • Implementation of technology including computerized prescriber order entry (CPOE) and barcoding;
  • A complete history and physical should be conducted;
  • Patients should be treated holistically; not just for their presenting complaints;
  • Get enough rest; and,
  • Always report near misses.

Finally, nurses are encouraged to trust their nursing knowledge, even when the order was written by an MD, filled by a pharmacist and already questioned once by a charge nurse. Never give a medicine that you question! noted one respondent.

Summary

Insufficient numbers of adequately experienced nurses on staff resulting in utilization of “float” nurses; as well as a lack of sufficient support staff to assist nurses in providing safe patient care are repeatedly implicated in medication errors. Registered nurses (RNs) were far and away the discipline most reported as being the individuals who prevented errors. The patient outcomes as described were overwhelmingly uneventful. Nurses are encouraged to trust their nursing knowledge, even when the order was written by an MD, filled by a pharmacist and already questioned once by a charge nurse. Never give a medicine that you question! noted one respondent.

References

1. Prevention of Adverse Drug Events. (accessed August 30, 2006). www.ihi.org/NR/rdonlyres/FDBB51E5-5402-46C6-B527-4120B7EB27EF/0/ade.pdf.

2. Classen, DC, Pestotnik, SL, Evans, RS, Lloyd, JF, and Burke, JP. Adverse drug events in hospitalized patients: Excess length of stay, extra costs, and attributable mortality. Journal of the American Medical Association, 1997:277:301-306.

3. Phillips, DP, Christenfeld, N and Glynn, LM. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet. 1998:35 1:643-644.

4. Rozich, JD and Resar, RK. Medication Safety: One organization's approach to the challenge. Journal of Clinical Outcomes Management. 2001; 8(10):27-34.

5. Rothschild, JM, Federico, FA, Gandhi, TK, Kaushal, R, Williams, DH and Bates, DW Analysis of medication-related malpractice claims. Causes, preventability, and costs. Archives of Internal Medicine . 2002:162:2414-2420.

6. Billman, G. Medication Coordination for Children with Cancer . Presentation at AAP Patient Safety Summit . May 21, 2002.

7. Branowicki, P. Sentinel events: Opportunities for change . Presentation at Massachusetts Coalition for the Prevention of Medical Errors Conference, November 18, 2002.

8. Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors (2006). Preventing Medication Errors. Washington, DC : National Academies Press.

9. Adams, K, and Corrigan, JM, Eds. Priority areas for national action: Transforming health care quality. Washington, DC : National Academies Press, 2003.

10. Gladstone, J. Drug administration errors: a study into factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing, 1995: 22: 628-37 .

11. Baker, H and Napthine, R. Medication error: the big stick to beat you with. Australian Nursing Journal ,  1994: 2.4: 28-30 .

12. Cooper, MC. Can a zero defects philosophy be applied to drug errors? Journal of Advanced Nursing, 1995: 21: 487-91.

13. Bechtel, GA, Vertees, JL and Swartzberg, B. A continuous quality improvement approach to medication administration. Journal of Nursing Quality Assurance, 1993: 7.3 : 28-34.

14. Keill, P and Johnson, T. Shifting gears: improving delivery of medications. Journal of Nursing Quality Assurance ,1993: 7.2: 24-33.

15. Booth, B.   Management of drug errors. Nursing Times, 1994: 90.15: 30-1.

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