Most common mistakes were wrong time, omission
A new report gives discouraging news on the rate of medication errors in hospitals. The research, reported in the Sept. 9 issue of the Archives of Internal Medicine, found frequent medication errors, occurring at a rate of nearly one in every five doses in the typical hospital and skilled nursing facility. The percentage of errors rated potentially harmful was 7%, or more than 40 per day per 300 inpatients, on average.
"This evidence of a high rate of medication errors in many of the institutions in the sample supports the implications of the Institute of Medicine report that the medication delivery and administration systems of the nation’s hospitals and skilled nursing facilities have major systems problems," the researchers write. The Institute of Medicine report said medical errors contribute to more than 1 million injuries and up to 98,000 deaths annually.
The study examined 36 institutions, including hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations, nonaccredited hospitals, and skilled nursing facilities in Georgia and Colorado. The target sample was 50 day-shift doses per nursing unit or until all doses for that medication pass were administered. Up to four different nursing units were included at each site if available, so that 200 doses per facility could have been observed.
All data were collected during 81 observation days from May 4 to Nov. 11, 1999. Medication errors were witnessed by observation and verified by a research pharmacist. An expert panel of physicians judged clinical significance.
Errors included wrong dose, unauthorized drug
In the 36 institutions, 19% of the doses were in error. The most frequent errors by category were wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). There was no significant difference between error rates in the three settings or by size. Error rates were higher in Colorado than in Georgia; researchers found the reason for this discrepancy to be unclear.
This study follows the Joint Commission’s July announcement of its National Patient Safety Goals for 2003. These goals focus on confusion in identifying patients, miscommunication among caregivers, wrong-site surgery, infusion pumps, medication mix-ups, and clinical alarm systems. Joint Commission-accredited health care organizations will be evaluated next year for compliance with these standards.
The 2003 National Patient Safety Goals and Recommendations are:
- Improving the accuracy of patient identification. The Joint Commission recommends that organizations use at least two patient identifiers (neither to be the patient’s room number) whenever taking blood samples or administering medications or blood products. Also, prior to the start of any surgical or invasive procedure, organizations should conduct a final verification process, such as a "time out," to confirm the correct patient, procedure, and site, using active communication techniques.
Read-back’ of orders recommended
- Improving the effectiveness of communication among caregivers. The Joint Commission recommends that organizations implement a process for taking verbal or telephone orders that requires a verification "read-back" of the complete order by the person receiving the order. In addition, organizations should standardize the abbreviations, acronyms, and symbols used throughout the organization, including a list of those not to use.
- Improving the safety of using high-alert medications. Health care organizations should remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, and sodium chloride >0.9%) from patient care units. They also should standardize and limit the number of drug concentrations available in the organization.
- Eliminating wrong-site, wrong-patient, and wrong-procedure surgery. Health care organizations should create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available. They also should implement a process to mark the surgical site and involve the patient in the marking process.
- Improving the safety of using infusion pumps. Health care organizations should ensure free-flow protection on all general-use and PCA intravenous infusion pumps used in the organization.
- Improving the effectiveness of clinical alarm systems. Finally, the Joint Commission recommends that health care organizations implement regular preventive maintenance and testing of alarm systems. They also should ensure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.
In other Joint Commission news, the American Society of Health-System Pharmacists in Bethesda, MD, reports that the Joint Commission won’t unveil its newly renamed medication-management standards until at least next spring. The standards, however, are still scheduled for implementation in January 2004. n
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