Medication Errors
Error reporting does a turnaround
Focus on where the system failed, not on how someone failed the system
When HealthSystem Minnesota in Minneapolis started its project on anonymous incident reporting a couple of years ago, the facility's track record on error reporting made an abrupt turnaround. In 1996, the facility participated in a 40-hospital collaborative run by the Boston-based Institute for Healthcare Improvement (IHI), whose goal was to identify and evaluate medical errors. HealthSystem Minnesota's quality improvement team now scores an A+ on error reporting.
HealthSystem Minnesota, comprising the 340-bed Methodist Hospital and 19 clinics, started its initiative on a small scale in March 1996. Just one medical/surgical ward was included at first. "We wanted to see if the project worked before we rolled it out hospitalwide and systemwide," says Judy Wilson, RN, CPHQ, manager of quality resources. The first step was to develop an anonymous, nonpunitive format for reporting medication events. The focus would be on where the system failed the individual, rather than on how the individual failed the system.
The old reporting format was punitive and not anonymous. The team wanted a form simple enough so people would use it, but detailed enough to provide information that could lead to action. The result was a half-page reporting questionnaire asking for the date and time of the event, where it occurred, a brief description, and the patient's response to the event. (See HealthSystem Minnesota's report form on p. 122.) On the reverse are definitions of what the team was looking for - adverse drug events and reactions, actual and potential - and examples of types of errors: prescribing, transcribing, dispensing, and administrative. Nurse managers collected the reports in a locked box and sent them to the quality resources department, where statistical analysis was performed.
HealthSystem Minnesota's project continued throughout 1996. "We reached our aim," says Wilson. "We had statistically significant improvement on reporting." The quality improvement team moved from learning types of errors to preparing Pareto bar graphs listing error incidence from highest to lowest. (See hypothetical examples of those graphs, p. 123.) Once the team had these, they could give immediate feedback to the units so staff could see where improvement was needed most and where they should begin their own performance improvement projects.
Clearly, simple human blunders are at the root of some errors, and egregious errors may ultimately become fodder for lawsuits. In addition, every facility is vulnerable to the chronically incompetent - perhaps even malicious - staff member, and that person cannot be ignored and allowed to go unpunished. If such a person makes the same mistake repeatedly, shouldn't the reporting mechanism pick that up? "Our organization has thought about that," says Wilson, "but we've learned through Lucian Leape's observational studies that blaming individuals does no good. If an individual is making medication errors, whether on purpose or through lack of knowledge, it's going to come out in other ways."
"The traditional approach of blaming individuals for mistakes doesn't get at the heart of the real problem," asserted Donald Berwick, MD, a pediatrician and president of IHI, in a statement released by the organization. A redesign of work processes and systems is what actually reduces and prevents errors, he said. (See related article on systemic remedies for correcting errors, p. 125.) The IHI's collaborative focused its efforts on six key areas:
· improving prescribing practices;
· safe handling of lethal drugs;
· standardizing the medication process;
· improving access to information;
· improving chemotherapy safety;
· facilitating error reporting.
"The majority of errors don't cause harm to a patient, but you can learn from them so as to avoid future errors that might cause harm," Wilson explains. One of the projects that came from the initiative had to do with transcription. After the physician writes an order, the health unit coordinator transcribes it to a medication administration record. Somewhere in that process, errors tend to occur. The team noted certain medications that need to be timed appropriately to avoid food and drug interactions, and made a statistically significant improvement on timing those meds. They not only attained their goal; they exceeded it. Another project involved RNs double-checking the transcription and co-signing the medication administration record. The team beat its goal on that initiative, too.
Once the team saw the model working on a small scale, it was time to roll it out hospitalwide to all nursing and patient care units. Lucian L. Leape, MD, chair of IHI's medical errors collaborative in 1995, was invited to speak to HealthSystem Minnesota's physicians, nurses, and nurse managers about the work of the IHI collaborative and their facility's accomplishments in February 1997.
"He shared other areas of success and raised our spirits for the launching of the project facility-wide in April," says Wilson.
With the help of the anonymous, nonpunitive reporting format, units throughout the hospital made statistically significant improvements. "To succeed," says Wilson, "an organization needs support from the top down - from your senior leadership right down to the front-line workers. Our senior leadership from our CEO right down supported our initiative financially and staffwise. They encouraged us to take time from our jobs for this project."
Hospital Peer Review asked how HealthSystem Minnesota's initiative fits in with the new sentinel event policy of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. "I think JCAHO will look favorably on our project when they come for their survey this fall," says Wilson. "It falls into the medication use and evaluation standards. The agency will probably see this as an active step in learning about our events and instituting improvement efforts and preventive measures."
Under any circumstances, the facility would conduct a root-cause analysis in the event of a sentinel episode, Wilson notes. The Joint Commission says if you choose not to report sentinel events, you must do a thorough analysis. If Joint Commission staff discover an unreported sentinel event, they would visit and require a root-cause analysis.
On HealthSystem's anonymous reporting form there is a spot for the medical record number so the team can go back to the chart if necessary for an analysis. "Since we don't go back to the individual and take punitive action," says Wilson, "we'd probably ask a representative from that area to participate in a root-cause analysis, go through the objective steps in the process to see where the error may have occurred."
Leape, affiliated with the Harvard School of Public Health in Boston, is leading a second medical errors collaborative in session this year. The team will present results in a few months. In Leape's observational study of the first collaborative, he wrote that during a six-month period, 334 errors were detected as causes of 264 adverse drug events in a random sample of 11 medical/surgical units in two New England facilities.1,2 The investigators identified 16 major systems failures as underlying causes, the most common of which was in the dissemination of drug knowledge, particularly to physicians. Systems failures accounted for 78% of the errors; the rest were attributable to simple human error. Of the 78%, inadequate availability of patient information, such as lab results, was associated with 18%. Leape and his colleagues concluded that the situation could be improved by better information systems.
"Leape's team noticed that the number of errors actually occurring was much higher than what was being reported in those facilities," says Wilson. The HealthSystem Minnesota team extrapolated the findings and determined, she says, "that clearly medical errors were being underreported in our facility. Our first aim was to increase reporting throughout the organization - to learn more about error types, then institute improvement projects around them."
References
1. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995; 274:35-43.
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.
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