Medication error tracking program cuts risk, impresses Joint Commission

Nurse input yields process and education changes

In the war to wipe out medication errors, a system that tracks when and why errors occur and follow-up education to prevent further errors are formidable weapons.

At the 166-bed, nonprofit Bucks County Hospital in Warminster, PA, a small group of nurses have taken a front-line initiative by developing a medication events tracking system that provides remedial education for nurses who make mistakes.

Hospital administrators have not been able to determine whether medication errors have dropped because the program has not been in place long enough to collect new medication errors data. But the system impressed inspectors from the Joint Commission on Accreditation of Healthcare Organizations during their March 1996 visit, hospital administrators say. The Joint Commission awarded the hospital an overall score of 96 out of a possible 100 points, in part because of the way the hospital now tracks medication errors and conducts follow-up education for nurses who make them, they say.

The Joint Commission requires hospitals to have a corrective action plan for medication errors as part of their performance improvement program, says Louis Head, MD, associate director of standards interpretation of the Joint Commission in Oakbrook Terrace, IL. Head rated Bucks County Hospital's medication error tracking and remediation system as excellent.

Bucks County Hospital is part of the five-hospital Medical College Hospitals system in Warminster, PA. Despite the lack of statistical evidence showing a reduction in medication events, the risk of events occurring is down thanks to the tracking system, says Nancy R. Cirone, MSN, RN, director of the hospital's nursing education department. In fact, many improvements have come from input from nurses taking part in remedial training, she emphasizes.

The system was designed for ease of use, say its developers. Medication errors are rated on one form, follow-up information on another, and the remediation plan spelled out on a third form. Cirone has received calls from other hospital administrators throughout the nation praising the system's user friendliness, she says. (See Medication Event Rating Grid, p. 91, and the four-page insert that includes a Medication Event Follow-Up Form.)

One potential problem did concern Cirone initially. She says she feared that tracking errors and putting nurses through remediation might discourage them from reporting medication events because they feared retribution, she says. Literature reinforced her concern. "We wanted people to continue to report," she says. "We didn't want to initiate a system that people thought was so punitive they wouldn't report an error," she says.

Cirone has seen no decrease in reported events, she says. She attributes this to the fact that nurses know if they make a mistake they will not be reprimanded or fired, but they will instead receive remedial training and counseling. Remedial training offers nurses a chance to talk about how badly they feel about making the error. Nurses come away knowing that making an error does not mean they are incompetent, and in fact many errors are caused by process problems, she says.

Handling medication events evenly

Back in 1994 before the system was developed, the hospital had no system for dealing with medication events, says Cheryl L. Mee, RN, MSN, now associate director for the journal Nursing 96 in Springhouse, PA. Mee was nurse manager on the medical/surgical unit at Bucks County and helped spearhead the system's development in 1994. She was also coauthor with Cirone and Carol V. Levinger, MSN, RN, of an article on the process they went through in creating a medication event rating grid.

"We had no real system or policy [when an event was discovered]," Mee says. "We basically just did what we thought was right." The education department's involvement was limited to a yearly inservice on medication errors.

Spurred by the Joint Commission's requirement for a medication events corrective action plan, the three women decided to establish a way to track and quantify events. In addition, they wanted to help nurses understand why they made a mistake and prevent future errors, Mee says.

First, they rated the severity of medication errors, Mee says. An ad hoc committee of clinicians and managers was formed to classify and quantify events with input from pharmacy and risk management, Mee says. This first step resulted in the Medication Event Rating Grid.

The committee then developed a Medication Event Follow-Up Form to collect details on events and a medication event remedial training plan to identify steps nurse managers would take depending on the seriousness of an event, Mee says.

When an error is reported, the nurse manager fills out the error follow-up form which provides details of the event, Cirone says. The mistake is assigned points depending on severity according to the grid. If a mistake rates five points or more, remedial training takes place, she says.

The first time a nurse is called into the education department for remedial training, he or she engages in a type of game-playing on a computer program called Medication Errors, Cirone says. Medication Errors is made by Computerized Education Systems in Orlando, FL. The program takes the nurse through a series of rooms where he or she must hand out medications. "Each time you give out medication there is another scenario asking what you should do," Cirone says. "You get a cumulative score at the end and if you miss the answer it [the program] gives you the rationale as to what the right answer is then and there."

If a nurse continues to make medication errors, he or she works on a self-learning module with problems tailored to the specific error, Cirone says. Cirone and the nurse manager also talk with the nurse to see what contributed to the error, and many of these discussions have led to improvements in the way medication is ordered and stored, she says

Transcription errors were the most common event because medication orders were squeezed in between other orders on the physician's order sheet and were easily missed or illegible. Since nurses couldn't read the orders, they sometimes transcribed them incorrectly -- an event which sometimes led to the patient receiving the wrong medication or receiving the medication at the wrong time. Sometimes, the order was missed altogether. One nurse recommended dividing the physician order sheet down the middle so physicians could write medication orders on the right and all other orders on the left. That change has reduced transcription errors from an average five to six per month in 1994 to an average two per month in 1995 and 1996, Cirone says.

Input from nurses has also led to the hospital purchasing new medication carts, Cirone says. Constant activity around the hospital's few carts distracted nurses and this led to events such as missing a medication dose. On the 42-bed medical/surgical floor, nurses, physicians, medical students, and other staff constantly worked around the floor's two medicine carts. Three more carts were purchased for the unit, and one additional cart was purchased for the other units. There are more carts so fewer people are gathered around the carts and the environment is less distracting for nurses, Cirone says.

The high number of medications on crash carts was reduced when nurses noted that the volume was confusing, Cirone says. A task force of respiratory therapists, pharmacy representatives, a central supply staff person, nurses, an educator, and a physician standardized crash cart medications throughout the hospital and deleted medications that were redundant or seldom used.

Nurses appreciate system's benefits

Nurses have reported approval of the system, Cirone says. From January 1995 to May 1996, 37 nurses went through remedial training. Each filled out a form asking whether he or she thought the process fair. (See the Medication Error Profile Survey included in four-page insert.) Two thought it unfair and this led to yet another change, Cirone says.

"One nurse thought it was punitive because she had to sit at the computer module in my office where anyone could see her and know what she was there for," she says. So Cirone moved the module to the library where she conducts a lot of computer training. Now, no one knows if a nurse is at the computer for remedial training or regular computer training.

Understanding and remedial training are used only to a point. If a nurse ignores the system and continues to cause medication events, he or she is dismissed, as two people have been so far, Cirone says. If a nurse accumulates a total of 15 points in a year, the case goes to management where it is reviewed. The nurse might be suspended for one day, or a corrective action plan might be required wherein the nurse writes of summary of the events, what contributed to them, and how they might be prevented in the future, Cirone says.

"Patient safety has to come first," Cirone emphasizes.

[Editor's note: The computer program, Medication Errors, is available for $250 from Computerized Educational Systems, 307 Park Lake Circle, Orlando, FL 32803. Telephone: (407) 841-6230 or (800) 275-1474.] *