Medication errors: What case managers can do

Strategies to prevent medication errors

By Ruth Davidhizar, RN, DNS, CS, FAAN
Dean of Nursing
Bethel College, Mishawaka, IN
Giny Lonser, RNC, BA, MSNc
Andrews University, Berrien Springs, MI

When the causes of medication errors are examined, a number of strategies to prevent errors can be identified. Adherence to these strategies can cause medication errors to be avoided:

1. Report all incidents, regardless of actual harm. In 1993, the Food and Drug Administration (FDA) established the MedWatch program, a voluntary program encouraging health care professionals to report when a medication, product, or medical error causes serious harm to patients. MedWatch allows medication error information to be collected nationally. Many of the errors reported in the 1999 United States Pharmacopeia (USP) study did not cause patient harm and are not part of the national data related to serious harm.

It is important for agencies to have information about the causes of potential errors as well as those that cause actual harm if the work environment is to be made safer. By analysis of actual and potential errors, a comprehensive plan can be made to address causes of errors, which may involve computer software, the medication administration environment, policies and procedures, staffing practice and policy, and use of a drug formulary.

The data collected in the l999 USP study prompted changes in staff education and other factors related to potential errors. When information concerning potential errors is collected, health care agencies will capture the causes of errors and provide a safety net to deter serious adverse events from occurring.

2. Utilize information from incident reports to establish safe care practices. Using a system such as MedMarx can provide the health care community with substantially more information on which to base safe care practices. Data enable research and hypothesis testing. The data can support both agency study and changes in policy and procedures. While this study revealed omissions to be the most common cause of error, further investigation into patterns of behavior at individual agencies is needed to determine the reasons omission errors occur at the individual institution. It may be that omissions actually are caused by a part of the system such as the turnaround time in dispensing that involve systems outside of the case manager’s control.

3. Involve a team approach in eliminating medication errors. While case managers are not primarily responsible for medication administration, the process involves a team: the prescriber, pharmacy, computer technology, the distribution system, and the patient record. Errors may be eliminated by making changes in any of these systems. Interven-tion must be collaborative and involve all team members to be most effective.

4. Evaluate adequacy of numbers and type of staff. An assessment of the qualifications of available personnel is important in determining if adequate numbers and types of staff are present to provide a safe medication administration process. Distractions and workload can contribute to performance deficits. When staff are working in unfamiliar surroundings, which occurs as staff are shifted off their primary unit to another, more errors occur. The case manager needs to be aware of this factor and promote stability in staffing patterns.

5. Provide education and updating regarding the medication procedure. Inexperienced staff, such as new graduates or staff detailed to an unfamiliar unit, are more prone to medication errors. Case managers can contribute to assisting new staff by having preceptors who can monitor for competency and training in the medication administration procedure for the unit and agency where they are assigned. Initial training and periodic review of the medication administration procedures assist staff to stay proficient with the procedure. New staff may be apprehensive with their new environment and forget basic procedures to maintain safe technique. Drug calculation also contributes to errors. A total of 81% of nurses studied by Bindler and Bayne (l991) were unable to correctly calculate medications 90% of the time, and 43.6% of test scores requiring calculations were below 70% accuracy. Case managers can promote initiation of processes to monitor nurse medication calculation abilities.

6. Evaluate medication policies/procedures for compatibility with client safety. Federal, state, and local regulations provide direction for medication policies and procedures. Federal law controls medication sales and distribution; medication testing, naming, and labeling; and the regulations of controlled substances. The National Formulary sets standards for medication strength, quality, purity, packaging, safety, labeling, and dose form. In addition, each agency may set institution policies and practices, which staff are expected to adhere to. The size of the institution, type of service provided, and the number of personnel employed influence policy. In some cases, the agency may be more restrictive than federal regulations.

To increase safety, policies and procedures must be in place and have built-in safeguards. Case managers should be aware of methods they can use to prevent medication errors with their clients. In the Fundamentals of Nursing, P. Potter and A. Perry provide tips on preventing errors.

7. Increase sensitivity of staff regarding medication errors. Safe practice is primarily based on attention to detail. Staff can avoid mistakes by taking time to confirm accuracy. Omissions and improper dosage are the most common cause of errors and can be avoided by actions related to alert and conscientious behavior.

Informing staff of errors as they occur can reduce medication errors by increasing awareness. Posted notices about common and uncommon errors can remind staff to be more attentive.

Recognition of staff who intercept potential errors can encourage others to participate in error-prevention activities. For example, a unit clerk checking medication while restocking noticed that, although drug packaging was identical, the medication was different.

By catching this mistake, errors in administration were prevented. The head nurse reported this astute behavior in every change of shift "report" for the next 24 hours; thus encouraging all staff to be more attentive. Recognition of the unit clerk illustrated that all members of the unit team are important in preventing medication errors. In addition, hospital staff worked with the pharmaceutical company regarding packaging of medication to diminish product confusion.

8. Encourage patient-centered care. When staff are familiar with patients, errors are decreased. Staff covering lunch relief or breaks are more prone to errors since they are unfamiliar with the patients or the unit’s routines. Also, they are more easily distracted, since surroundings are not familiar. Practices such as rotating patient assignments to give staff and patients variety can contribute to errors. The medication administration process should focus on the patient and the patient’s response in terms of signs and symptoms indicating adverse reactions or lack of a therapeutic response. Focus on the patient also involves follow up to ensure the desired outcome was achieved.

9. Evaluate staff competency in relation to performance. Providing pay raises for persons who have not made errors can discourage self-reporting of medication errors. Reinforcement should be provided in a way that enhances carefulness while not reinforcing dishonesty. Raises for not making errors can be seen as punitive for persons who have made errors and reported them.

10. Attention to staff stress can decrease errors. In a study by O. Brown, "Effects of a stress management program on nurse absenteeism," a stress management program was implemented consisting of 12 two-hour sessions. In collecting pretest anxiety and medication error rates, results revealed the experimental group who had intervention for their anxiety had 62.5% fewer errors as compared to 44.5% percent fewer errors in the control group. Thus, attention to staff stress was a significant deterrent to medication errors.

Case managers need to contribute to the safety of the therapeutic environment in order to achieve excellent patient outcomes. The 1999 USP study provided significant findings related to causes of medication errors. Openness in providing information about errors is a critical first step in learning how to avoid them. The 10 strategies presented here can assist in designing safe medication administration practices.

Recommended reading

• Bindler R, Bayne T. Medication calculation ability of registered nurses. Journal of Nursing Scholarship l991; 23(4), 221-224.

• Brown O. Effects of a stress management program on nurse absenteeism, medication errors, and anxiety. Doctoral dissertation, University of New Mexico 1990. Dissertation Abstracts International.

• Kohn L, Corrigan J, Donaldson M. (Eds.) To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

• National Coordinating Council. National council focuses on coordinating error reduction efforts. USP Quality Review Jan 1997; 57.

• Potter P, Perry A. Fundamentals of Nursing. St. Louis: Mosby; 2001.

• U.S. Pharmacopeia. Summary of the 1999 Information Submitted to MedMARX. Rockville, MD; 2000. 

Tips on Preventing Errors

  • Read medication labels carefully.
  • Question administration of multiple tablets or vials from single doses.
  • Be aware of medications with similar names.
  • Check decimal points.
  • Question abrupt and excessive increases in dosages.
  • When new or unfamiliar medication is ordered, consult resource.
  • Do not administer medication ordered by nickname or unofficial abbreviations.
  • Do not attempt to decipher illegible writing.
  • Know clients with same last names. Ask clients to state their full names. Check name bands carefully.
  • Do not confuse equivalents.