Medication Errors and Risk Management in Hospitals

Medication errors are a serious threat to patient safety in both hospitals and in the community. Risk managers are taking a more proactive approach to preventing medication incidents in hospitals. This has been exemplified during my recent contacts with hospitals in the metropolitan Toronto area. There is evidently support for a change in culture in organizations, from a suppressive and closed error reporting culture to a more open and non-punitive culture. Most importantly, there is commitment to implementing quality improvement initiatives to ensure safer medication use systems in our hospitals.

Although medication error reduction and prevention efforts need to be made by all health care disciplines, at all levels of the hospital, risk managers have a unique and important role to play:

• Facilitate the creation of an open and non-punitive culture in the organization to encourage error reporting, to ensure learning from error occurs, and ensure improvement needs are identified.

• Encourage reporting of "near-misses" to identify areas for improvement before an incident occurs.

• Coordinate educational sessions for staff to discuss errors and their prevention strategies.

• Focus efforts on specific high alert drugs and error-prone situations. References are available which identify these areas.^1,2

• Perform an objective self-assessment of the hospital's risk for medication errors.

• Be involved in the review and "root-cause" analysis of medication errors.

• Participate and provide input into the development of quality improvement initiatives.

• Share error reduction and prevention strategies and other patient safety information with the other facilities

In this article I would like to highlight two very important strategies for health care administration, risk managers and practitioners. Firstly, DISCOURAGE BENCHMARKING OF MEDICATION ERROR RATES. It is unfortunate that many healthcare facilities still believe that their "error rate" is a measure of patient safety. The true incidence of medication errors will vary, depending very much on the vigor with which errors are identified and reported. Although many hospitals have a relatively standardized method to define a medication incident (a medication error that reaches a patient), the manner in which they are detected and the efforts to report them differ widely.

Simply comparing "numbers" of medication errors lacks validity, and more importantly can dangerously undermine efforts for full reporting. A high error rate could suggest unsafe medication practices or it could reflect an organizational culture which promotes error reporting. Likewise, low error rates may suggest a successful error prevention program or may be the result of an inherent punitive approach which inhibits individuals from reporting errors and analyzing causes of errors. Hospitals which focus their attention on maintaining a "low error rate", will inadvertently promote an unproductive cycle of underreporting of errors, and allow unrecognized weaknesses in the medication use system to continue. Low error rates can result in a false sense of security and an implicit acceptance of preventable errors. A focus on error rates derived from spontaneous reporting systems often places pressure on practitioners to report fewer errors. A hospital's strategy should be to place less emphasis on comparing error rates calculated from the spontaneous reports received, and instead, should encourage open and full error reporting to identify and remedy system problems.³

The question then arises "How do Risk Managers measure the safety of medication use and the effectiveness of error prevention strategies within their organization"? According to Michael Cohen, co-founder and president of ISMP (US), analyzing the causes of actual incidents and potential incidents and implementing changes to address these causes, and measuring outcomes of the change is an effective and more meaningful way to gauge error prevention efforts. ISMP (US) has also developed a self-assessment tool which hospitals in the US, can use to measure whether or not, basic recommendations for safe medication practices have been incorporated into a hospital's medication use systems. The self assessment tool is currently being adapted for Canadian Hospital use.

The second important issue is the extraordinary similarities existing between infection control management and medication error prevention.^1,2 To illustrate this, consider that both nosocomial infections and medication errors occur in hospitals, are prevalent and can both be potentially costly in human and financial terms. In both scenarios, one must distinguish between the preventable and non-preventable events and, with rare exceptions, there are no "silver bullets" to eliminate problems identified. Both areas of prevention strategies require evaluating and searching through multiple systems and possible causes. Risk Managers and all disciplines committed to preventing errors can benefit from the vast body of knowledge, research, and experience that has been gained through the many infection control efforts made. Over a decade ago, research ^1,2 confirmed that hospitals with a low incidence of nosocomial infections had BOTH strong surveillance programs AND strong prevention/control programs. Today, regulatory, accrediting, and other infection control advisory bodies recommend that hospitals employ specifically trained, dedicated practitioners to identify the presence of nosocomial infections AND coordinate an effective infection control plan". Typically, infection control surveillance is focused on high priority areas with increased risk of serious infections, such as intensive care units, and surgical patients etc. The CDC no longer recommends the use of an overall nosocomial infection rate from hospital-wide surveillance for hospital comparisons. Such broad determinations are left to researchers and focused research. Trained infection control practitioners collect data on nosocomial infections in a uniform manner from multiple sources, rather than relying only on information that may be readily available through self-reports or medical records abstractors. Extensive time is devoted to analysis of the data, implementation of infection control strategies, evaluation of their effectiveness, education and dissemination of the information.

Wouldn't our medication error reduction efforts be more productive if: 1) we employed specially trained and dedicated practitioners to uniformly identify the presence of medication errors through a variety of sources, rather than depending primarily on self-reporting programs; 2) our error detection efforts were followed with analysis of the data, review of the literature, implementation of system-based error reduction strategies, and candid dissemination of information to all those who need to know; 3) our efforts were more focused on high alert drugs and other predictors of serious medication errors; and 4) we, along with the regulatory, accrediting, and advisory bodies, placed less emphasis on determining overall error rates for comparison and left such to the researchers? There is no doubt we can learn to do better by learning from another setting.

There is a great deal of reference material available to risk managers, which discusses documented reported actual and potential medication errors and also suggests recommendations to prevent errors in healthcare organizations. One excellent source of information is the Medication Safety Alert! newsletter published biweekly by the Institute for Safe Medication Practices (ISMP) located in Huntingdon Valley, Pennsylvania. This newsletter is a subscription service provided by ISMP to over 6000 hospitals, other healthcare organizations and practitioners in the US. ISMP shares information with ISMP Canada, a sister organization in Canada. Should you like to have a complimentary copy of the newsletter, please send your request via email to info@ismp-canada.org.

ISMP Canada is an independent nonprofit organization established for the collection and analysis of medication error reports and the development of recommendations for the enhancement of patient safety. ISMP Canada also intends to serve as a national resource for promoting safe medication practices throughout the health care community in Canada. For additional information, please visit our web site : www.ismp-canada.org.

References:

1. ISMP Medication Safety Alert! vol.4, issue 23, November 17,1999
2. Medication Errors, edited by Michael Cohen, published by APhA, 1999.
3. ISMP Medication Safety Alert! vol.3, issue 18, September 9, 1998