Help me summarize thisInnovation in practice: A muidisciplinary medication safety initiativeEid, Khaled Al
At the University of California Irvine Medical Center, in Orange, Calif., Khaled Al Eid is a clinical nurse specialist.
The author has disclosed that he has no financial relationships related to this article.
AS REPORTED BY the Institute of Medicine in a landmark study, medication errors are responsible for an alarming number of deaths in hospitals.1 Reporting and analyzing medication errors at the institution level is recommended to help understand and prevent medication errors.2 Numerous models, processes, and practices have been utilized to improve medication safety within hospitals.3 This article discusses the successful implementation of a medication safety committee to review and analyze all medication errors and improve processes for medication administration.
Back to Top
Reforming an ineffective process
Our institution’s efforts to identify medication errors were historically centralized and ineffective. A muidisciplinary group of physicians, pharmacists, nurse managers, nurse educators, and clinical nurse specialists had a monthly meeting to review error trends for the entire institution and discuss selected events. Using this approach, organizational issues that led to errors weren’t identified, and individual cases were reviewed without attendance by appropriate stakeholders. No representatives from the units involved were present to explain possible reasons why an error occurred in their area, which minimized the concept of ownership and accountability for errors in patient-care areas. Feedback to specific physicians, pharmacists, and nurses was solely dependent on their reading meeting minutes. Hence, similar errors continued to occur over time.
Back to Top
Creating a committee
In 2010, the organization restructured the review of medication errors into a medication safety committee that oversaw six operational subcommittees: medical/surgical, critical care, women children’s services, perioperative services, ambulatory care, and behavioral heah. This approach was initiated because of best practices emanating from our neonatal ICU (NICU). The NICU clinical nurse specialist (CNS) leads the initiative and clinical nurses participate in the critical review of medication events specific to their unit.The nursing director of the medical/surgical division empowered our leadership to assume responsibility for errors and to change our processes related to the review of medication safety issues. Currently, the medical/surgical medication safety committee (a divisional committee that reports to the house-wide safety committee) is chaired by the medical/surgical CNS. Other committee members include medication safety unit champions (clinical nurses) from each medical/surgical unit, the hospital medication safety officer, pharmacists, a physician representative for medical house staff, the medical/surgical nurse educators, and the oncology CNS.An average of 60 to 70 events per month (such as medication errors, near-misses, adverse drug reactions, hypoglycemic events, and uncharted controlled substances) are presented at committee meetings and analyzed in depth. The incidents are identified by unit, date, time, description of the event as it happened, who discovered the event, who reported the event, the outcome of the event, and where in the medication preparation and distribution process the event happened. Incidents are also categorized as they relate to prescribing, order communication, labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, and education. The events are analyzed by the CNS committee chair (divisional level and CNS-led) and a pharmacist to determine the cause. The clinical nurse medication unit champions review the incidents from their areas and come prepared to discuss their findings. During the meeting, the event is projected on a screen and unit representatives present the incident with their findings. The committee analyzes the event and discusses what factors contributed to it.Resus of the analysis are reported to the house-wide medication safety committee, where the CMO, CNO, nursing directors, pharmacy director, medication safety officer, risk manager, information technology personnel, and chairs of all divisional subcommittees analyze overall trends. Medication Error Reduction Plan and harm potential categories are used to classify events. The medical/surgical CNS is responsible for bringing the reports to the divisional practice council. The committee chair (medical/surgical CNS) also presents a report to the organizational medication safety committee, a subcommittee of the pharmacy and therapeutics committee. The medication safety unit champions identify critical incidents to report to their respective unit practice councils.
Back to Top
Since the inception of this initiative, over 3,000 medication events have been critiqued by nursing units. The major causative factors in medication errors include failing to follow the seven rights of medication administration (right patient, right medication, right dose, right route, right time, right indication, and right documentation), not checking orders, use of incorrect medication concentrations, failure to read the entire order, and not addressing special instructions.4 Our medication management policies have been modified to reflect current evidence-based practice. For example, a dose verification process was implemented for certain high-alert drugs using the following steps:* The administering practitioner withdraws the medication into a syringe.* A second qualified practitioner looks at the syringe containing the medication and the container from which the medication was withdrawn to verify that the intended medication and dose were prepared.5An independent double-check is performed for high-risk drugs such as chemotherapeutic agents, insulin and heparin infusions, heparin flushes in the NICU, epidural analgesics, and investigational drugs.6 Independent double-checks are conducted while a clinician programs a pump and at handoff. The process begins when the administering practitioner programs the pump. Before the infusion is started, a second qualified practitioner independently reviews the order, the patient’s identity, the label on the medication, and the pump setting. The correct medication, concentration, and pump setting are confirmed against the order. The literature suggests that 95% of errors can be detected by independent double checks.6Figure. Medication e…
Opens a popup window
Opens a popup window
Opens a popup window
In addition, the following interventions were implemented:* Mandatory electronic record checks every 4 hours. With new orders, nurses see a flag next to the patient name in the electronic medical record. They have to go in the list to see what’s been flagged and actively remove the flag to acknowledge that they’ve received the order.* Hourly bedside rounding by clinicians, including bedside handoff. Following this protocol, nurses include the patient in the report while they review what’s infusing and if it’s appropriate. Rounding also allows clinicians to check for the patient’s basic needs, such as toileting, pain relief, repositioning, and safety.* Quiet zones around the medication area to diminish distractions.* Computers added to the medication room next to the automated medication dispensing system to verify orders.* Implementation of bar code technology.A special subcommittee was formed to focus on hypoglycemia events, resuing in a new protocol for managing blood glucose levels. This included a guide for prescribers to support patients with diabetes who are N.P.O.
Back to Top
Our data have demonstrated a significant decline in the number of medication errors that reached patients, while near-misses continue to be reported. (See Medication events reported by medical/surgical units.) For example, this past March report had only one medication error and seven near-misses-we considered this a great accomplishment by the nurses. Plans for the future include evaluating data from the bar code scanning to determine if any near-misses weren’t reported. We’re also in the process of creating an automatic reminder for when a medication’s peak and trough levels must be checked.Nurses at our institution have become successful advocates in reducing medication errors at the prescribing, dispensing, and administering levels. This nurse-led exemplar testifies to the effectiveness of a muidisciplinary initiative to prevent medication errors and improve patient safety.