Case Scenario
A 32-year-old G2 P1 undergoes an elective induction of labor at 39 weeks. She is admitted at 6 AM. The night nurse works quickly to complete her admission and get the induction process started. Oxytocin is ordered along with a mainline intravenous (IV) of D5LR running at 125 ml/hr. On this unit, it is standard practice for the oxytocin to be run on a pump while the mainline runs free flow at a rate that is eyeballed by the nurse.
In her haste, the mainline is put on a pump and the oxytocin is free flowed, thus switching the two IV bags. It is not until the next nurse arrives on the day shift that this medication error is recognized as part of her routine care. By this time the patient is contracting every two minutes and re-recurrent late decelerations are noted on the external fetal monitor. Fortunately, due to the astute care of this oncoming senior nurse, the error is quickly recognized and corrected with intrauterine resuscitation measures. Ultimately, there is no harm to the mother or baby. This is just one example of the impact of medication errors on patient safety. The following article will provide an overview of medication errors and strategies to improve medication safety.
Medication Errors
The scenario above demonstrates one of many types of errors that can occur during the medication process. Medication errors have been defined as:
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (Hughes & Blegan, 2008, p.2-398).
Implications of Medication Errors
The magnitude of medication errors has been highlighted in the literature, with studies showing the number of preventable drug-related injuries in hospitals to be as high as 400,000 per year, adding an estimated financial burden of 3.5 billion dollars (American College of Obstetrics and Gynecologists, 2016). The importance of medication safety cannot be understated given the current challenges within healthcare including increased workloads, short staffing, inadequate patient safety and quality education for healthcare providers, illegible prescriptions, and faulty dispensing systems (Hughes & Blegen, 2008). In addition, human factors such as fatigue, distractions, and communication failures can also contribute to medication errors. (American College of Obstetrics and Gynecologists, 2016).
The Medication Process
The medication process involves 5 stages: (a) ordering/prescribing, (b) transcribing and verifying, (c) dispensing and delivering, (d) administering, and (e) monitoring and reporting (Hughes & Blegan, 2008). The majority of medication errors occur at the ordering or administration phase and include causes such as wrong dosage, unknown allergies, illegible handwritten orders, and incomplete electronic prescriptions (American College of Obstetrics and Gynecologists, 2016). Mitigation strategies have been developed to target the different stages in the medication process. Several of these will be discussed in further detail including the 5 rights of the medication administration process, bar code scanning, independent double-check for high alert medications, electronic order entry system, electronic prescribing (e-prescribing), and allergy alerts.
Strategies to Improve Medication Safety
Basic medication safety starts with individuals following the 5 “rights” of the medication administration process and refers to the right patient, drug, dose, route, and time. This fundamental safety practice is taught as part of the standard nursing school curriculum. Bar code medication administration processes (BCMA) serve as a way to electronically verify the 5 rights and thus further strengthens this process. These systems involve scanning a barcode on a patient’s wristband and on the medication to be delivered, which interfaces with a computer software system designed to produce warnings or approvals (Shah et.al., 2016). It’s important to note that barcoding does not eliminate errors completely and therefore does not replace checking the 5 rights. The following is an example of one such error.
A nurse drew up a medication for a patient in another room and mistakenly administered the medication to [another] patient. The [nurse] scanned each medication; however, the nurse went into the wrong room, scanned the patient’s bar code, and did not check the screen prior to giving medication to the patient. The screen did verify that it was the wrong patient. The patient received three incorrect medications (Pennsylvania Patient Safety Authority, 2008, p. 124).
In this case, verifying patient identification, along with bringing the computer into the room to allow viewing the screen, would have helped to mitigate this error.
Independent double checks include two people reviewing the appropriate process separately. This reduces the risk of confirmation bias that can occur when one person influences the other by potentially suggesting what the person double-checking should find. When done correctly, studies have shown that up to 95% of errors can be detected with the use of independent double checks (Institute for Safe Medication Practices, 2019).
Electronic order entry refers to a computerized system of ordering medications to ensure complete and legible orders. Standardized order sets for patient-specific diagnoses can also be utilized to help guide best practice in certain scenarios- for example, the use of standardized order sets for the treatment of severe hypertension in the pregnant/postpartum patient. E-prescribing allows prescribers to directly send prescriptions electronically to a pharmacy and has similar benefits as electronic orders: complete and legible orders. It is usually part of the electronic medical record system or it can exist as a freestanding system. Both electronic order entry and e-prescribing offer the benefits of clinical decision support systems containing drug and allergy alerts, along with disease-specific contraindications (American College of Obstetrics and Gynecologists, 2016).
In summary, the scope of medication safety and mitigation strategies is broad. There are many different individuals and systems-level approaches to improving safety in this area. This article highlighted approaches involving basic nursing medication safety practice, health information technology, and peer cross-checking.
References
American College of Obstetricians and Gynecologists (2012, reaffirmed 2016). Improving
Medication Safety. Committee Opinion No. 531. Obstet Gynecol,120,p.1-5.
Hughes RG, Blegen MA. Medication Administration Safety. In: Hughes RG, editor. Patient
Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency
for Healthcare Research and Quality (US); 2008. Chapter 37. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK2656/
Institute for Safe Medication Practices (2019). Independent Double Checks: Worth the Effort if Used
Judiciously and Properly. Retrieved from https://www.ismp.org/resources/independent-double-checks-worth-effort-if-used-judiciously-and-properly
Kieran Shah, Clifford Lo, Michele Babich, Nicole W Tsao, Nick J Bansback (2016). Bar Code
Medication Administration Technology: A Systematic Review of Impact on Patient Safety
When Used with Computerized Prescriber Order Entry and Automated Dispensing
Devices. Can J Hosp Pharm, 69(5), p.394–402. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5085324/
Pennsylvania Patient Safety Authority (2008). Pennsylvania Patient Safety Advisory, 5(4),
p.122-126. Available from
http://patientsafety.pa.gov/ADVISORIES/documents/200812_122.pdf
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS