Do you report medication near-misses? Here’s what Joint Commission wants
Do you report medication near-misses? Here’s what Joint Commission wants
Patients are safer if you report mistakes and potential errors
You drew up penicillin for an allergic patient but caught it just in time. You gave a patient the wrong dosage of a sedative, but luckily no harm was done. Grabbing an unlabeled syringe, you almost administered the wrong medication — one that could have killed your patient.
No patients were harmed, so which of these incidents is worth reporting? All of them, say ED nurses at hospitals with nonpunitive reporting systems.
At Methodist Hospital in Indianapolis, a "Safe Passage" program encourages nurses to report safety concerns, even when errors are caught in time, and has increased reports by more than 300%, reports Mary Ross, RN, a charge nurse in the ED. "There are always mistakes waiting to happen in the ED," Ross says. "Nurses bring these safety concerns to my attention all the time. If somebody makes a mistake and you don’t figure out the root cause, it’s bound to happen again."
By airing near-misses, underlying system problems are detected that put patients at risk, she notes. Due to concerns reported by nurses, new insulin syringes likely to cause dosing errors were removed from the ED, and "look-alike" medications were moved to separate drawers in the automated medication dispenser.
Even with a nonpunitive system, it takes time for nurses to become comfortable reporting their mistakes, Ross notes. "Previously, if your name was on an occurrence report, you got in all kinds of trouble," she says. "Nurses were afraid if they admitted making a mistake, that they would be fired."
Nurses fill out a form that asks for their name and for witnesses to the incident. "The person filling out the report is not necessarily the person who made the error," Ross points out.
In addition, the ED has just started offering web-based occurrence reporting with the Morrisey Concurrent Care Manager system (manufactured by Boca Raton, FL-based Eclipsys), which can be done anonymously.
"You hear the incident report, but there is always a story that goes along with it that you are not hearing," says Ross. "We need to learn from our mistakes and pass it on so others don’t make the same mistake."
At Spectrum Health System in Grand Rapids, MI, a "Good Catch" program rewards nurses for reporting "near miss" mistakes that didn’t reach the patient, with more than 10,000 "catches" reported to the database.
Brightly colored "Good Catch" cards are available in the break rooms and medication areas so nurses can report near misses and suggest what can be done to make patients safer.
"We are really encouraging nurses to notice whenever they do things that aren’t mistakes yet," says Deborah Keim, RN, ED nurse manager for Spectrum Health’s Butterworth campus.
Nurses reported concerns about medications that are given in more than one dosage, so pharmacy put a notation on these medications to remind nurses to check the dosing strength. For example, the 1 mg vial of hydromorphone says "for ED only."
When nurses report potential problems, their actions can stop an untoward event, says Janice Smolinski, RN, ED nurse manager at Spectrum’s Blodgett campus. "Nurses now pay very close attention to detail, such as noticing whether the correct medication is in the correct drawer," she says.
When nurses report a "catch," their names go in a hat to be drawn for a monthly prize such as lunch or coffee mugs. "They are rewarded for catching something that could keep someone else from making a mistake," says Smolinski.
Share your own mistakes
To encourage reporting, Keim talks openly about her own errors. "We tell our own stories as much as possible," she says. "We have a new grad program where we all go around and tell the worst mistake we’ve ever made."
One of Keim’s own examples involves giving tenfold less than the correct dosage while sedating a patient. When the medication was given, there was no effect and the respiratory therapist caught the error, she recalls. "We were doing it at the bedside, so I probably figured the dose in my head, which is not a good thing to do," Keim says. "No harm was done, but what if the mistake had gone the other way — and the patient had gotten 10 times the dose?"
As a result of this incident, a "double-check" process is used for sedation medications and insulin, with a line on the medication order sheet for two nurses to sign. The ED also is investing in an electronic medication administration system: FirstNet Emergency Medicine Information System, manufactured by Kansas City, MO-based Cerner Corp. That system will be integrated with the automatic medication dispenser to make it easy for nurses to retrieve correct drugs and dosages.
"If you are up front about your own mistakes, other nurses see that it’s not the end of the world to admit an error," says Keim. "Here, covering up a mistake will get you into much more trouble than reporting an error will."
Ross recently hung an intravenous line with the antibiotic piperacillin and tazobactam, and she didn’t realize that this drug was contraindicated for patients allergic to penicillin. "Another nurse saw it and told me that she had made the same mistake a week earlier," says Ross. The solution was to put in a pop-up screen that appears whenever the medication is selected, asking, "Is the patient allergic to penicillin?" "I am honest about the mistakes I make, to encourage others to come out of the closet," says Ross.
Surveyors from the Joint Commission on Accreditation of Healthcare Organizations want to see that your ED has effective systems in place to identify, report, and analyze adverse events. "Most of the safety-related requirements get high priority on survey, and error reporting is certainly one of them," says Richard J. Croteau, MD, the Joint Commission’s executive director of patient safety initiatives.
Surveyors don’t want to hear, "We don’t have any problems with medication errors in our ED,’" says Croteau. "That is truly a red flag," he says. "It’s either flat-out denial or a totally inadequate process for recognizing when things are going wrong. Our surveyors are tuned into that, and will start looking more deeply into the culture of the organization," he says. For example, they will ask about whether a reporting system exists and, if so, why it isn’t being used.
There is a growing trend toward openness in error reporting, with a systems analysis rather than a focus on individual behavior, says Croteau. "The easier and less threatening it is to report, the more reports you are going to get, and the better chance you will have of knowing what’s actually going on," he says.
One key characteristic of an effective reporting system is that nurses who report concerns get feedback, says Croteau. "It is a real incentive for people to report, if they get information back and see that something is being done," he says. "If they don’t get that, they will stop reporting."
At Spectrum Health, the ED manager must do a follow-up report that is shared with the staff member who reported the concern. "Part of the report includes the questions, Is there anything that could have prevented this?’ and What follow-up actions were taken?’" says Keim.
"This is where we would report coaching, corrective action, or referral to a team to correct the problem," she adds. "Several times, nurses who made the error have done teaching for other staff."
Sources/Resources
For more information on medication safety in the ED, contact:
- Deborah Keim, RN, Nurse Manager, Spectrum Health-Butterworth Campus, 100 Michigan St. N.E., Grand Rapids, MI 49503. Telephone: (616) 391-3592. E-mail: [email protected].
- Mary J. Ross, RN, BSN, CEN, Emergency Medicine Trauma Center, Methodist Hospital at Clarian Health Partners, 1801 N. Senate Blvd., Indianapolis, IN 46202. Telephone: (317) 962-8355. Fax: (317) 962-0841. E-mail: [email protected].
- Janice Smolinski, RN, Emergency Department, Spectrum Health-Blodgett Campus, 1840 Wealthy St. S.E., Grand Rapids, MI 49506. Telephone: (616) 774-5159. E-mail: [email protected].
- The Comprehensive Unit-Based Safety Program (CUSP) allows staff to focus safety efforts on unit-specific problems by targeting system failures and not individual fault. The eCUSP is an electronic version of CUSP. For more information, contact: The Patient Safety Group, Six Walnut St., No. 4, Boston, MA 02108. Telephone: (617) 620-6320. E-mail: [email protected]. Web: www.patientsafetygroup.org.
- The Quantros Safety & Risk system is a web-based system that automates incident collection, follow-up, root-cause analysis, and regulatory reporting for health care organizations. For more information, contact: Quantros, 690 N. McCarthy Blvd., Suite 200, Milpitas, CA 95035. Telephone: (408) 957-3300. Fax: (408) 957-3320. E-mail: [email protected]. Web: www.quantros.com.
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