Improving the Reporting of Medication Errors: PROMOTING A CULTURE OF SAFETY
PROMOTING A CULTURE OF SAFETY
A culture of fear stifles creativity and innovation, and it impedes continuous improvement by enabling defects to remain undetected—or unreported. Fear fosters gaps between “what we know” and “what we do.” To close this gap, it is imperative to promote and to support a culture in which staff members can search for defects and can continually seek and eliminate the flaws in the system. When employees are afraid or hesitant, productivity suffers. Fear drives people to remove the source of fear, not the source of the problem. Improved performance cannot occur unless staff members feel comfortable in reporting defects and speaking truthfully and are confident thattheir suggestions will be taken seriously.
In the 2005 Patient Safety Culture Survey (total respondents = 601), the staff gave VA-NYHHS a mean patient safety grade of 3.97 (acceptable, borderline very good), which was higher than the means of the Veterans Integrated Service Network (VISN 3) (3.89) and the VA nationally (3.87). Despite that high overall grade, the NYHHS grade was below the VA national mean for the following patient safety dimensions: Nonpunitive Response to Error (-0.86) and Perceptions of Patient Safety at Your Facility (-0.12). These results indicated that the VA-NYHHS staff was still associating incident reporting with punitive consequences.
The interdisciplinary committee at the VA-NYHHS promoted the new reporting tool through educational awareness. Through this awareness, the interdisciplinary team also communicated the value of reporting close calls, not only adverse events, to Quality Management. Reporting close calls provides an opportunity to investigate a potential systems problem without inadvertently causing patient harm. The Nursing Informatics Coordinator educated all nursing staff to report “missing dose requests sent to pharmacy” as a result of delivery of the wrong drug or dose to Quality Management via the Medication Error Evaluation Report. tadalis sx
In addition, incident reporting and medication management are addressed through the VA-NYHHS’s monthly Priority Focus Area (PFA) Tracer Rounds. Using the methodology of the Joint Commission on Accreditation of Healthcare Organizations, Quality Management staff and nurse educators paired up to conduct those tracer rounds on specific topics. While doing so, every effort was made to reverse the prevailing perception that reporting medication errors would result in punitive consequences. Errors in the delivery of health care are common and are widely recognized as resulting from system failures. Medication errors result from poor systems and human psychology rather than from poor performance. The interdisciplinary team focused on the conditions under which individuals work and tried to avert errors or mitigate their effect. To promote the culture of safety and to increase reporting of close calls and adverse events at the VA-NYHHS, the interdisciplinary committee asked the P&T committee to review the data and to suggest ways to reward employees for reporting close calls and adverse events.
As we have learned, the efforts of the interdisciplinary committee have paid off handsomely. So far, for three quarters only, in fiscal year 2007, 156 medication close calls and adverse events (see Figure 2) have been reported to Quality Management—a 156% increase from the total medication errors reported in fiscal year 2006 (see Figure 1).
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The increase in reporting has given the Medication Error Committee and newly formed Patient Safety Committee a robust supply of data to work with and better insight into the most prevalent systems issues contributing to close calls and adverse events. To date, the Patient Safety Committee has facilitated the following actions to reduce medication errors:
• Reviewed a medication error in which the ACE-inhibitor benazepril (Lotensin, Novartis) was ordered instead of the antiallergy and antiparkinson agent Benadryl (diphen-hydramine, Pfizer). The Patient Safety Committee recom¬mended that “tall man” lettering would be used for both BenaDRYL and BenaZEPRiL.
• Reviewed an incident in which a stat (immediate) order of the antimicrobial agent vancomycin (Vancocin, Baxter) was not administered until three hours later. The Patient Safety Committee recommended that stat orders be printed on a different printer in the pharmacy.
• Eliminated the potential for an overdose error involving hydrocortisone. After reviewing an incident in which an excessive dose of hydrocortisone (500 mg) was ordered or administered, the Patient Safety Committee decided to eliminate the option of ordering this amount of the drug from the Computerized Patient Record System’s menu.
All of those systems vulnerabilities were identified and were able to be corrected because of the increase in medication error reporting. Defects in a system can be seen as thorns or roses. Whereas some managers fear the unearthing of defects, enlightened leaders welcome their discovery and, in fact, encourage the staff to actively seek them out. Defects are treasures to be valued because they present opportunities for improvement. Only by identifying flaws in the system can we identify—and correct—the fundamental or systemic root causes of errors.
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Acknowledgments. We offer special thanks to Dr. Andrew J. Adler, Deputy Chief of Staff, and Cynthia Caroselli, RN, PhD, Associate Director of Patient Services, for their assistance and support in this endeavor. Thanks to Jane Matuszewski, RPh, Quality Assurance Specialist, and John Ward, RPh, MS, Clinical Pharmacy Specialist, for helping us follow trends in medication errors. Also, thank you to Marilena Antonopoulos, PharmD, and Samuel Grossman, PharmD, Clinical Pharmacy Specialists, for their assistance with training the pharmacy residents and pharmacy students on how to report medication errors using the revised Medication Error Evaluation Form.
