How to reduce errors through verification and double checks
Weigh burden versus benefits
Hospital pharmacies need to continually weigh the scales between risks of medication errors and costs of more vigilant medication distribution monitoring.
Err too much on the side of keeping costs down, and a single error could have long-term implications. Monitor every single medication given to patients and the department's costs would skyrocket.
"Medication checks can add burden and take time and resources," says Carole A. Stockmeier, MHA, CMQ/OE, a partner and practice director of Healthcare Performance Improvement (HPI) of Virginia Beach, VA. Stockmeier spoke about the use of double checks at the ASHP summer meeting and exposition, held June 6-9, 2010, in Tampa, FL.
"So the value of a check is the degree to which the benefit is greater than the burden," she says.
"If you introduced unnecessary burden into the system, it can increase employee noncompliance," she adds. "So assess the risk of the process and the consequences of process failure and the probability of failure."
Stockmeier explains how to create a checks and balance system that reduces risk while making the most efficient use of available hospital pharmacy resources:
Assess risks and processes in designing verification system: First, determine the consequence of failure, Stockmeier suggests.
"If there's a significant consequence of harm or death then that would need a higher level of checks and verifications," she says. "If there's minimal or no harm potential, then you shouldn't add burden to the process."
For example, any process that involves blood products would have a high level of risk; any process involving an over-the-counter drug to treat an upset stomach likely would be considered low risk, low consequence, she adds.
The next step would be to assess the degree to which your system already has error proofing.
"There are a lot of processes where human error is possible," Stockmeier says. "If an error is possible with a high consequence, then you'd want to have a higher amount of rigorousness."
The third step is to look at task complexity, she says.
"If a task is simple and easy for people to remember how to perform, then you need to have less rigor in checking," Stockmeier says. "If it's complex then you'll need more rigor."
An example might be the degree of complexity in preparing a tablet, which is a simple process, versus preparing a neonatal total parenteral nutrition (TPN), which is complex and requires lots of steps, she adds.
Assign level of check and verification to each process: "You have to look at the risk of the process at hand and then determine what is the appropriate level of checks," Stockmeier says.
"It's not who makes the decision," she notes. "It's how you make the decision."
The key is to have experts involved in the decision-making process, and this typically means a combination of pharmacy and nursing staff, she adds.
Here are the various levels of verification and check, from simplest to most rigorous:
–Self-check: This is the simplest, least time-consuming, and most cost-effective of the checks.
"You type an e-mail, reread that e-mail to make sure there are no misspellings in it, and you send it," Stockmeier says. "Self-checks are tasks you can perform and get in the habit of doing during your daily work."
For example, a pharmacist who is entering an order into an electronic order entry system should perform a self-check to make certain the order is placed accurately.
"Visually, with your finger on the piece of paper and the other on the computer, make sure every order and dose listed on what the physician gave you is entered accurately into the computer system," Stockmeier suggests.
–Peer check: When pharmacists perform a calculation of a weight-based dose for a patient and then hand their work over to another pharmacist to quickly check, this is a peer check.
"You informally ask someone else to check it out, but this is not written into procedures," Stockmeier says.
–2nd person concurrent validation: Validation is something people are familiar with doing, and it's a thought process of whether something makes sense and fits in with what the person performing the task knows is true or correct, she explains.
When validation is concurrent, this means a person is assessing the validity at the same time another person is performing the task, she adds.
"We think about this when we're administering the drug, standing there together, and having our eyes on the drug label and the patient's arm band," Stockmeier says. "We're looking at all of the elements at the same time."
–2nd person independent validation: In this case, one person is administering the medication and looking at the label and patient's arm band, and then that person hands it over to another person to independently check.
"They look at those three elements and make sure they match together," Stockmeier says.
A good example of this process is when a pharmacists provides a second check of a pharmacy technician's work, she adds.
–2nd person independent verification: In this case, a pharmacist is asking a second person who has expertise that is different from the pharmacist's to provide verification of the process.
This level of checking is resource-intensive and would be used in high-risk cases, such as during risky surgical procedures, Stockmeier says.
In general, pharmacy directors and staff should think about checks and verification in terms of how thorough a check is necessary, depending on the level of risk and available resources.
Then these decisions should be communicated to everyone involved in the checks and verification.
"It's important when we design a check for a process that we clarify for our people and are explicit in what type of checks we want to be performed," Stockmeier says.
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