June 14, 2011 (Chicago, Illinois) — Editor's note: Safe medication administration depends on the individual nurse using her intellect and the available technology; however, system issues can compromise safety. Medication errors cost billions of dollars and cause injury and death. Anatomy of a Fatal Medication Error was featured as a podium presentation here at the American Association of Critical-Care Nurses (AACN) 2011 National Teaching Institute & Critical Care Exposition, held April 30 to May 5.
To find out more about medication safety and error prevention, Medscape Medical News interviewed Pamela A. Brown, RN, PhD, CCRN, nurse manager of the pediatric intensive care unit at Doernbecher Children's Hospital at Oregon Health and Science University in Portland. She has more than 30 years of experience working in pediatric intensive care units. During her career, Dr. Brown has functioned in multiple roles, including staff nurse, clinical nurse specialist, and manager.
Medscape: The 5 rights of medication administration — the right patient, the right drug, the right dose, the right route, and the right time — focus on individual performance, and ignore system defects that can affect medication administration safety. What additions would you make to the 5 rights to address system safeguards?
Dr. Brown: The nurse has always been in the position of failsafe in medication delivery, which is a 3-tiered process: the MD orders the medication, a pharmacist prepares the medication, and the nurse administers the medication. If the physician makes an error, there are 2 chances to catch it. If a pharmacist makes an error, there is 1 chance to catch it. If the nurse makes an error, it often reaches the patient.
The "rights" of administration are in place to help the nurse create order and routine in a chaotic environment. The rights have been expanded in some sources to 6, 7, or 10 rights. Much like a professional golfer ensures his success with putting by always following the same routine before hitting the ball, the 5 rights applied in a consistent and strict manner will provide a high level of patient safety.
I would add a similar set of rights to the order and the preparation and distribution of the medications. The frustrations that nurses encounter, prior to the administration of the medication — following up on incorrect or incomplete orders or waiting for timely and correct delivery — can lead to rushing or skipping steps at the point of delivery.
Medscape: Can you describe the technologic processes in current use to promote medication administration safety?
Dr. Brown: Bar-code medication administration is a rising technology in hospitals. In this process, the nurse prepares the medication at the patient's bedside, and follows these steps: the nurse bar codes the patients identification tag (right patient); bar codes the medication, which matches the medication with the order (right medication, route, dosage, and time); and then administers the medication and bar codes or signs the patient's Medication Administration Record.
Medscape: What constitutes a medication error?
Dr. Brown: There are many definitions found in the literature. I prefer a simple yet comprehensive definition — any error occurring in the medication use process.
Medscape: How often are medication errors made? What are the annual morbidity and mortality rates related to medication errors in the United States? What economic costs are associated with medication errors?
Dr. Brown: The following are commonly cited statistics:
The true number of medication errors in a year is unknown because many go unreported, especially if there was no harm to the patient. One estimate is that a medication error occurs in approximately 1 of every 5 doses given in hospitals; another is that 1 error occurs per patient per day.
1.3 million people are injured and approximately 7000 deaths occur each year in the United States.
Drug-related morbidity and mortality is estimated to cost $177 billion in the United States.
Medscape: Has the use of technology contributed to less cognitive attention when it comes to medication administration? What are consequences of this?
Dr. Brown: Technology is not a panacea. Individuals can develop a dependence on the technology, and if there are no alerts in the process, sometimes they make assumptions that everything was done correctly. However, technology is dependent on human factors. The system is only as good as the people operating it. Errors can still be made in ordering and dispensing that may not be caught by the bar-coding system alone. In addition, the bar-code scanners frequently fail, requiring nurses to revert to administering medications without the technology on which they have come to rely.
Medscape: "What do you mean by "inattentional blindness"?
Dr. Brown: Inattentional blindness is the failure to notice a fully visible but unexpected object because attention was engaged on another task, event, or object. The individual performing a task fails to see what is plainly visible, and later cannot explain the lapse. On average, your brain scans about 30 to 40 pieces of information per second. The attention filter selects a small amount of information to process, and the rest never reaches consciousness. The brain fills in the gaps, compiling an integrated portrait of reality based on incomplete information. Inattentional blindness is more likely to occur if part of an individual's attention is diverted to another task. This is a common hazard in medication administration, as nurses are often thinking about and doing several things simultaneously.
Medscape: The title of your presentation was Anatomy of a Fatal Medication Error. Can you describe the circumstances of this fatal error?
Dr. Brown: A pediatric patient received a dose of a medication used to treat seizures that was 10 times the amount ordered. The error was the result of a combination of errors by the individual nurse and systems issues. Briefly, the nurse misread the screen on the automatic dispensing cabinet and consequently on the vial. This resulted in the nurse failing to dilute the medication as recommended. The pharmacy had stocked a 10 mL vial of the medication in the unit and was unaware that the Institute for Safe Medication Practices had recommended that only 2 mL vials of the medication be stocked in children's hospitals because of the occurrence of 12 previous deaths associated with the higher medication strength. In this case, the medication was given in an urgent situation. Because of concerns about reliability with delivery times from the pharmacy, the physicians and nurses decided to remove the medication from the unit's automatic dispensing cabinet instead of waiting for the pharmacy to deliver it.
Medscape: What advice would you give educators about teaching medication error prevention?
Dr. Brown: When I was teaching at a university, I recall that students frequently observed unsafe practices that could undo in one shift every principle that I had been trying to instill. I challenged my students to think about the kind of nursing care they would want for the person they loved most in the world, and then provide that same level of quality for each patient in their care. The work of nursing is complex. It is physically and mentally demanding and it requires our full attention at all times. To keep patients safe, we must recognize our own fallibilities and strictly follow the safeguards in place to prevent medication errors.
Medscape: What was the most important point of your presentation?
Dr. Brown: For patients to be safe in our care, individual healthcare providers must be aware of their own fallibility and consistently and reliably follow the rules and practices that are in place to protect the patients from harm — never taking for granted the magnitude of our obligations and the vulnerability of the patients in our care.
Medscape: Is there anything that you would like to add?
Dr. Brown: It is time to set aside historic practices and examine the high-consequence work we do in new and innovative ways. We need to know what the hazards are, and work to identify and fix system issues that do not support safe practice. Too often nurses "work around" systems problems, thinking they are acting in the patient's best interest, but in fact, a work-around increases the risk to patient safety.
Dr. Brown has disclosed no relevant financial relationships.
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Cite this: Medication Error Prevention: A Shared Responsibility - Medscape - Jun 14, 2011.