Use better documentation to head off ED errors

USP offers tips to help prevent medication errors

It’s no secret that the fast-paced and often crowded environment at many emergency departments (EDs) can pose problems not faced in other, more sedate levels of care. And it’s perhaps no surprise that many of the factors that cause inadequate documentation in the ED also can lead to medication errors.

"I think what we see is that, in other areas of the hospital — and I have to admit it’s not the best there, either — there seems to be some kind of a process," says Diane Cousins, RPh, vice president of Rockville, MD-based U.S. Pharmacopeia’s (USP) Center for the Advancement of Patient Safety. "Typically, things happen in sequence, so that before a medication is administered, a verbal order has to have been documented." The order then usually is reviewed by the pharmacy or someone else on the floor before the dose is prepared for the patient.

Lack of sequential processes

"So usually there’s some sequential processes," Cousins says, that provide for double-checking and give clinicians a pause in which they can gather themselves and make sure they’re providing the right dose for the right patient at the right time. "I think that’s what we see so differently here [in the ED] — that, because it is a fast-paced environment, you don’t have sequential processes where one task must occur before a second task is able to be completed."

Recently, USP identified leading medication errors in hospital EDs and offered tips for preventing medication errors in this critical setting. The recommendations were created after USP analyzed medication error data from its national databases containing more than 360,000 medication error reports since its inception in 1998. In 2001, hospitals reported more than 2,000 ED-related medication errors.

Not surprisingly, many of these errors have a documentation component. Cousins cites one example in which a nurse received a verbal order from the physician. Two nurses were in the patient’s room. One went to get and prepare the medication. The second went to transcribe the verbal order. After transcribing the order, she also got and administered the medication to the patient — so the patient was dosed twice. "So the first nurse didn’t get the chance to document it before she gave the med, and the second nurse gave the med presuming that if she transcribed [the order] that she also would also administer it," she says.

Errors of omission can occur in a similar way, she notes. "You could imagine that both left the patient’s bedside and one went and documented the order and presumed the other was giving it. The other didn’t give it, presuming the one who documented it would give it," Cousins says.

Clearly delineate responsibilities

Such problems can arise when multiple people are with the patient at a point in time, as often is the case in the ED. On a patient care unit, by contrast, you’re more likely to have a sequence such as: "The physician goes to the bedside, visits the patient, comes back to the nursing station, prepares the order; nurse goes to the bedside, checks the patient, leaves, prepares the does, returns to the bedside," Cousins says.

In the ED, where care is less predictable, it’s still helpful to clearly delineate responsibilities so that for a given patient everyone knows, for example, who is documenting, who is administering, and who is repeating back the verbal order to the physician, Cousins notes.

Another helpful step would be to institute a system of computerized physician order entry (CPOE), something that only about 5% of hospitals have done so far, according to the Leapfrog Group of Washington, DC. The Leapfrog Group has advocated strongly in favor of wider use of CPOE. Cousins notes that as much as 20% of hospitals may be moving toward the use of CPOE, but many more have not yet committed to do so.

CPOE issues

In a CPOE system, physician orders such as medications, lab tests, diagnostic tests, and other clinical care orders, are entered electronically and automatically transferred to the next area, such as the pharmacy or to nurses, effectively reducing the number of "hand-offs" of information. One facility that has made extensive use of CPOE, Montefiore Medical Center in Bronx, NY, has achieved a 60% reduction in the time elapsed from writing a prescription to a patient receiving the medication, and a 50% reduction in the number of potential prescribing errors.

Given the potential upside, why aren’t more facilities using CPOE? The answer is twofold, according to Cousins. First, there are no national standards concerning what a CPOE system should include. In the absence of such standards, "there have been efforts within the hospital to try to make those decisions, and oftentimes as you can imagine, there’s a lot of disagreement among physicians as to what those rules should be," she says.

The second issue is cost. Most facilities recognize that the best way to build a CPOE system is to integrate it with other information systems within the hospital, and such an undertaking can be costly. It can come down to a matter of priorities, Cousins says. "There are systems, for example, that use barcode bedside technology. How does that technology fit into the CPOE system?"

Even beyond CPOE, there’s little question that documenting with computerized systems can have a positive effect on error reduction — not just on the front end, but on the back end as well, by detecting variances. "For example, you might review the drugs administered to patients during a single-day period and find how many narcotic antagonists have been administered," Cousins says. "That would be a clue, for example, that a narcotic overdose may have been administered."

Cousins does caution, however, that computerized systems are not a panacea for error reduction. Indeed, computer entry is one of the most common causes of medication errors. "We’re finding that there are new errors that may arise because of the application of technology," she says.