Are your patients at risk for medication errors? Here’s how to avoid mistakes
Staff shortages, overcrowding make errors more likely
It’s every ED nurse’s nightmare. A 12-month-old infant with a gastrointestinal virus was incorrectly prescribed in the ED. The child was given two overdoses of belladonna alkaloids with phenobarbital and two doses of promethazine suppositories (contraindicated in children under 2 years), and discharged. Later that day, the unconscious infant was readmitted and suffered permanent brain injury.
The reality is that medication errors occur all too frequently in the ED, so you must take steps to avoid them, urges Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, director of emergency/trauma services for University of California-Irvine Medical Center in Orange. (See story on how to use protocols and checklists wisely, p. 136; improve access to information, p. 137; and standardize, p. 138.)
Medication errors have been in the spotlight since reports were issued by three health care organizations, including the Boston-based Institute for Healthcare Improvement, the Washington, DC-based Institute of Medicine, and the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. (For ordering information, see resources box, p. 135.)
The ED is at higher risk for medication errors than other departments, says Robert Wears, MD, MS, FACEP, professor in the department of emergency medicine at the University of Florida College of Medicine in Jacksonville.
"There is greater time pressure with less information about patients’ allergies and concurrent medications," Wears explains.
Also, the pharmacy generally doesn’t prepare the drugs for administration in the ED, in contrast to most inpatient units, Wears notes. "That means the preparation is done by a nurse who’s got a billion other things to do at the same time," he says.
The problem is exacerbated by current trends, argues Reneé Semonin Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at University Hospital in Cincinnati. "Staff shortages may be placing nurses with limited nursing and critical care experience in the ED," she says. "Also, both ED nurses and their physician colleagues are stressed by patient loads, which sets up the potential for mistakes."
Distribute allergy bands
Here are key steps in avoiding medication errors from ED experts and the reports:
• Give patients allergy bands at triage.
A recent study showed that failure to identify patient allergies is a common cause of medication errors in pediatric EDs, notes Bradley.1
At University of California-Irvine’s ED, the triage nurse gives every patient an allergy band attached to his or her name band. "Every time the nurse gives any medication, the name and allergy are checked simultaneously," she says.
Patients in the treatment area are often seen by more than one staff person, notes Bradley. "Because work loads fluctuate, the primary nurse may be pulled away from her assignment to fill in elsewhere," she says.
Before any medication is given to the patient, the patient’s name tag is verified by the nurse, and a secondary check is made on the allergy band to verify that the patient is not allergic to the drug that will be given, Bradley says. The allergy band is also used when the patient’s medical record is not immediately available, says Bradley.
"The drug order may be written on the physician order sheet, but the allergy may not be listed on the form," she explains. "As a secondary precaution, an error may be prevented if the nurse is attuned to checking the allergy bracelet."
Remember that some allergies might preclude all medications in a certain class and others might not, Holleran stresses. For example, you need to know if a patient’s allergy to penicillin precludes him or her from taking other antibiotics, she says.
• Educate patients about medications.
Medication errors by patients can be avoided with education, Bradley says. "We use many patient education materials that help us educate our patients on incompatibilities, adverse reactions, and side effects," she adds.
Currently, the ED is implementing a system to teach patients about the effects that herbal therapies can have on their prescribed medications, Bradley reports.
"We are finding that many of our patients are self-medicating with herbal medications," she says. "They are unaware of the incompatibilities that may exist with their prescribed medications and the adverse effects they may have on body systems such as the liver."
• Identify high-risk medications.
Most medication errors are caused by specific drugs, known as "high-alert" medications, according to the Joint Commission and the Huntingdon Valley, PA-based Institute for Safe Medication Practices.2
The top five high-alert medications are:
— insulin;
— opiates and narcotics;
— injectable potassium chloride (or phosphate) concentrate;
— intravenous anticoagulants (heparin);
— sodium chloride solutions above 0.9%.
According to the Joint Commission, common risk factors that lead to errors in administering those drugs include unclear labeling, a lack of a check system for medication dosages, and similar drugs kept in close proximity to each other.
• Implement a check system.
Use a check-back system in which all verbal orders are repeated back verbatim, recommends Wears. This practice caught a verbal order for 1 mg of vecuronium, which was heard as 10 mg of vecuronium, he says.
When a patient with a rapid heart rate needed to be given verapamil at Rhode Island Hospital’s ED, the wrong drug was almost given. "I inadvertently asked for Valium first, and then Versed. Those are two commonly used medications with similar sounding names, but absolutely wrong for the situation," recalls Andrew Sucov, MD, FAEM, medical director of the Providence-based ED. "Fortunately, I caught the mistake before either was given."
If the ED nurse had questioned why a benzodiazapene was being given for superventricular tachycardia, that would have alerted Sucov to the error sooner, he reports. "That would have prompted me to think harder for a second and get the correct medication," he explains.
Check-backs/call-outs ensure that you receive the correct medication, says Sucov. "This by itself won’t prevent misspeaking, but it will ensure that you hear the proper medication," he notes.
Understand the patient’s condition
• Know the care plan.
You must understand the overall care plan for the patient to be able to catch medication errors, stresses Sucov. "This way, you can be sure that the medication you’re giving is indicated for this problem," he says.
The best solution is for the ED nurse to understand what the patient’s condition is, so that when the physician does/does not order a medication that is appropriate for the condition, the nurse can identify whether that care makes sense, he explains.
• Review the basics.
A review of basic medication administration may be useful for all ED nurses, suggests Holleran. "Managers may want to consider quick quizzes for drug review at a staff meeting," she says. "This could be fun, as well as educational."
Check with colleagues whenever you are unsure about a medication or a dose, says Holleran. "Know who you can contact when you don’t know what a medication is or does, such as the pharmacist assigned to your area," she says.
• Avoid "sound-alikes."
Medication errors might occur if drugs have a similar-sounding name, such as the antibiotics cephalexin and ceftizox, says Sue French, RN, care center director of the pediatric and adult emergency medicine at the University of Chicago Hospitals.
To avoid this type of error, label drugs with the generic and trade name, Bradley advises. "This prevents confusion between drugs that are similar in sounds or spelling," she says.
Double-checking medication sounds like a simple solution, but it would prevent an error 99% of the time, argues French. "At the bedside, I always look one more time at the order and medication label before I give it," she says. "Even if another nurse draws it up for me, I request to see the vial." (See related stories on tools to help you avoid errors, p. 139; and ways to safely store medications, below.)
References
1. Selbst SM, Fein JA, Osterhoudt K, et al. Medication errors in a pediatric emergency department. Pediatr Emerg Care 1999; 15:1-4.
2. Cohen MR, Proux SM, Crawford SY, et al. Survey of hospital systems and common serious medication errors. J Health Care Risk Management 1998; 18:16-27.
The Institute of Medicine report, To Err is Human: Building a Safer Health System, is available for $34.95 plus a $4.50 shipping charge. To order, contact:
• National Academy Press, 2101 Constitution Ave. N.W., Lockbox 285, Washington, DC 20055. Telephone: (888) 624-8373 or (202) 334-3313. Fax: (202) 334-2451. E-mail: [email protected]. Web: www.nap.edu.
The bulletin on medication errors issued by the Joint Commission on Accreditation of Healthcare Organizations was published in Sentinel Event Alert. The complete text can be found on the Joint Commission’s Web site at www.jcaho.org. (Click on "for health care professionals," then "sentinel events," then "sentinel event alert," and select the Nov. 19, 1999, bulletin titled High Alert Medications and Patient Safety.) A Feb. 27, 1998, bulletin on Medication Error Prevention: Potassium Chloride is also available. To get the latest copy of Sentinel Event Alert faxed, call the Joint Commission’s fax-on-demand line at (630) 792-3885.
The Institute for Healthcare Improvement (IHI) has published a guide titled Breakthrough Series: Reducing Adverse Drug Events. The guide includes strategies for improving ordering systems, the dispensing process, administration of medications, and basic prevention strategies. The IHI also sponsors the annual National Forum on Quality Improvement in Health Care, to be held Dec. 5-8, 2000, in San Francisco, which will address adverse drug events. To order a copy of the guide, which costs $49.95 plus $7 shipping and handling, contact:
• Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215. Telephone: (617) 754-4800. Fax: (617) 754-4848. Web: www.ihi.org.
The Institute for Safe Medication Practices (ISMP) provides education about adverse drug events and their prevention through the ISMP Medication Safety Alert, a biweekly resource sent by fax or e-mail for $135 annual subscription fee. For more information, contact:
• ISMP, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Telephone: (215) 947-7797. Fax: (215) 914-1492. E-mail: [email protected]. Web site: www.ismp.org.
The following databases for health care professionals are available from Micromedex:
• Poisindex. Information on commercial product ingredients (drug and nondrug) linked to clinical treatment guidelines for managing exposures.
• Drugdex. Extensive drug monograph information detailing the therapeutic use, dosing, and adverse effects of pharmaceuticals. Includes uses not approved by the Food and Drug Administration.
• Emergindex. Detailed information to assist emergency physicians in managing acute care situations.
• Drug-Reax. An interactive database that provides information on potential drug interactions.
• AltMedDex. Detailed monographs outlining scientific information available regarding use, dosing, and adverse effects of herbal medicines and alternative therapies.
For more information, contact:
• Micromedex, 6200 S. Syracuse Way, Suite 300, Englewood, CO 80111. Telephone: (800) 525-9083 or (303) 486-6400. E-mail: [email protected]. Web site: www.micromedex.com.
For more information about how to avoid medication errors in the ED, contact:
• Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, Emergency/Trauma Services, University of California-Irvine Medical Center, 101 The City Drive, Route 128, Orange, CA 92868-3298. Telephone: (714) 456-5248. Fax: (714) 456-5390. E-mail: [email protected].
• Sue French, RN, The University of Chicago Hospitals, Pediatric and Adult Emergency Medicine, 5841 S. Maryland, MC 5068, Chicago, IL 60637. Telephone: (773) 702-1014. Fax: (773) 834-1100. E-mail: [email protected].
• Reneé Semonin Holleran, RN, PhD, University Hospital, P.O. Box 670736, Cincinnati, OH 45267. Telephone: (513) 584-7522. Fax: (513) 584-4533. E-mail: [email protected].
• Andrew Sucov, MD, Rhode Island Hospital, 593 Eddy St., Davol 141, Providence, RI 02903. Telephone: (401) 444-8388. Fax: (401) 444-4307. E-mail: [email protected].
• Robert L. Wears, MD, MS, FACEP, University of Florida Health Center, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 549-4124. Fax: (904) 549-4508. E-mail: [email protected].
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