Follow these 11 steps for error prevention
In the long run, effective error prevention for most hospitals will require substantial redesign of their medication systems, says Lucian Leape, MD, chair of the Institute for Healthcare Improvement and adjunct professor of health policy at Harvard School of Public Health, both in Boston. However, in the short run, organizations can achieve substantial gains in patient safety by implementing widely accepted processes and procedures that have proven to be effective, he says.
"Most of these can be implemented promptly without prior data collection or analysis of errors and provide a sure way to prevent or greatly reduce certain errors." Here are several to consider, according to Leape:
1. Enforce standardized prescribing. Many errors result from sloppy or hurried prescribing practices: abbreviating, using code symbols, or leaving out elements of the order. Well-publicized and firmly enforced prescribing rules will reduce errors.
Here are some rules for standardized prescribing:
• Use the word "unit," not "u" or "U."
• Do not use the letter "Q" or "q" (QD, QID, etc.). Use "every."
• Use a leading zero (0.1 mg, not .1 mg) but not a trailing zero (2 mg, not 2.0 mg).
• Include all elements of the order: dose, strength, units (metric), route, frequency, and rate.
• Use full names (preferably generic).
• Use only authorized abbreviations.
• Use the metric system only.
2. Simplify. Complexity is a cause of error. The more steps, handoffs, and communication required in a process, the greater the likelihood of error. Eliminating any of the steps in a process reduces the likelihood. Streamlining even a part of the medication system almost always reduces errors. Changes to simplify the process include:
• Eliminate the transcription process by computerization or automatic copying of orders.
• Limit the number of possible concentrations for a drug, particularly high-hazard drugs such as morphine and heparin.
• Limit the types of infusion pumps to one or two.
3. Standardize multiple processes. Widely used in other industries, standardization is the simplest, most broadly applicable and effective method for reducing errors. Standardization is a form of simplification. If all personnel know and follow a single procedure or practice, they are more likely to discover errors made by others. Candidates for standardization include:
• doses;
• times of administration (such as antibiotics);
• packaging and labeling;
• storage (such as placing medications in the same place in each unit);
• dosing scales (such as insulin and potassium);
• protocols for the use and storage of potentially lethal drugs — potassium injection, insulin, lidocaine, sodium chloride injection, calcium injection, magnesium injection, chemotherapeutic agents, heparin, dextrose injection, narcotics, adrenergic agonists, and theophylline.
4. Use unit dosing. Unit dosing, introduced 20 or more years ago, is perhaps the most powerful change ever implemented in the medication system. It substitutes routine and repetitive pharmacist calculation and dispensing with the nonroutine process of the nurse preparing each individual medication, which is a different calculation and task each time. While somewhat more expansive than bulk dispensing and on-site preparation, unit dosing costs less overall by virtue of preventing errors in drug administration that could have far more costly results, Leape says.
5. Use pharmacy-based admixture of intravenous medications. The error-preventive effect of pharmacy IV admixture is analogous to that of unit dosing. Both are examples of the improved efficiency and accuracy that result from specialization. IV calculations and mixing are ad hoc, on-the-spot events when performed on the nursing unit and are fraught with error because they are performed occasionally and with a multitude of drugs. In a pharmacy admixture program, standardization and repetition make errors much less likely.
6. Use error-preventive packaging. The Food and Drug Administration and drug manufacturers have not done all they can to ensure that pharmacists and nurses easily can distinguish drugs from each other, according to Leape. "Look-alike" packages and ambiguous or unclear labels lead to errors. Pharmacies can repackage look-alikes and provide distinctive packages and labels for lethal drugs. They also can ensure the labels on all drugs have clear, dark, large, and easy-to-read type.
7. Make allergy information available. Too often, hospitalized patients receive drugs to which they have a known allergy. Hospitals with programs ensuring that all parties — doctors, pharmacists, and nurses — have allergy information available when they need it for each patient have reduced that risk substantially. This information should be prominently displayed on the order sheets, in the pharmacy, and on the medication administration record.
8. Eliminate too-long or double shifts. Fatigue degrades performance; tired workers make more errors. Health care is unique among the hazardous industries (such as aviation or nuclear power) in often ignoring that well-known fact, Leape says.
9. Use computerized drug profiling in the pharmacy. Every pharmacy should have a complete drug database for each patient against which staff can check each new prescription before dispensing the medication. This check system should identify therapeutic duplication, contradictory orders, and potentially harmful drug-drug interactions.
10. Institute a 24-hour pharmacy service. Only pharmacists should dispense medications, Leape advises. Permitting nonpharmacy personnel (such as the nursing supervisor) to access the pharmacy during off hours is unwise, he says. If there is doubt that this is a problem, ask, "Would anyone sanction the reverse: a pharmacist substituting for the nurse or physician during off hours?"
11. Have an effective system to monitor and report adverse drug events. Few hospitals are aware of the extent of adverse drug events because staff, fearing punishment or because the reporting system is too complex, do not report errors. According to Leape, when hospitals create a nonpunitive environment and encourage and reward reporting, they will begin to understand the nature and extent of their adverse drug events, which is the first step toward redesigning systems to reduce errors.
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