By Jennifer Larson,
NurseZone feature writer
Given
the old adage that “to err is human,” medication errors are a perennial
issue in health care. But reducing the number of medication errors and
increasing patient safety should be a perennial goal, two researchers told a
group of California nurses Oct. 10 at the California Nursing Outcomes Coalition
(CalNOC) conference in San Diego, California.
Nurses
always need to remember they are responsible for protecting a patient about to
receive a drug, said Frank G. Saya, Pharm.D, president of the California Society
of Health-System Pharmacists and manager of pharmacy services at Cedars-Sinai
Medical Center and Research Institute.
“[Nurses]
are really the last safety net,” he said.
But,
he added, “People are not infallible.”
The
National Coordinating Council for Medication Error Reporting and Prevention
defines an 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 health care professional, patient, or consumer.”
Linda
Burnes Bolton, RN, DrPH, FAAN, added that medication administration is not the
No. 1 error when it comes to medical errors; the dubious honor goes to the
ordering or prescribing of medication, which is a physician’s responsibility.
With
that in mind, CalNOC is looking at ways that nurses can reduce errors, said
Burnes Bolton, vice president and chief nursing officer of Cedars-Sinai.
The
CalNOC Medication Safety Initiative proposes several medication safety
indicators. Nurses are encouraged to verify patients’ allergies, label any
drugs prior to administration and educate patients about medications they are
prescribed in order to decrease the chance for error.
Also,
nurses need to watch out for omitted doses, as well as doses administered at the
wrong time or in the wrong manner or amount, said Burnes Bolton.
Patients
“are counting on us …to be able to assist them,” she said.
CalNOC
will be soliciting participation in the initiative with the goal of collecting
and analyzing data for measures to further improve patient safety.
In
another session at the conference, Patricia Benner, RN, PhD, FAAN, described
three approaches to errors: individual professional responsibility, systems
design and practice responsibility.
Practice
responsibility is not as well-known in the literature as the first two
approaches, but it is just as important to have “a socially embedded knowledge
with notions of good internal to it” when caring for patients, said Benner, a
professor in the University of California San Francisco School of Nursing.
Practice
responsibility requires more than scientific knowledge and technology; it
requires experiential learning and holding up high standards of care every day
alongside colleagues, she said.
“Nursing
is not like football,” she said. “It is not about competitive
individualism.”
The
California Healthcare Foundation advises facilities to create a “culture of
safety,” or an environment of overall heightened awareness of medication
errors with commitment from leadership to prevent errors.
The
foundation is the philanthropic arm of Well-Point Health Networks, a for-profit
corporation that was formerly the non-profit Blue Cross of California.
Regardless
of an organization’s technological solutions, the strategy should include
appropriate safety processes, such as the checking of patient wristbands and
documenting allergy information, according to the foundation. But it recommends
a baseline assessment of problem areas and opportunities for improvement and a
plan for educating both staff and patients on medication safety.
The
issue is a nationwide concern. At least 44,000 patients die each year in the
United States as the result of some type of medical error, accounting for the
eighth leading cause of death in this country, Saya said.
Even
more people are at risk, according to the Institute of Medicine. A 1999 report, To
Err is Human: Building a Safer Health System, estimated as many as 98,000
Americans may die annually due to medical mistakes. However, the U.S. Department
of Health and Human Services is more conservative in its estimates, putting the
number between 44,000-98,000 patients.
Medication
errors are also one of the top five causes cited in all malpractice claims, Saya
told the CalNOC conference.
In
fact, the problem is serious enough to have warranted $50 million in new funding
from HHS. On Oct. 12, HHS Secretary Tommy G. Thompson announced the release of
the funding from the department’s Agency for Healthcare Research and Quality
for 94 new research grants and projects aimed at reducing medical errors and
improving patient safety.
October 19, 2001 © 2001 NurseZone.com All Rights Reserved.