1. Patient Safety, Medication Errors, and “At-risk” Behaviors Christine M. Wilson Advanced Concepts of Pharmacology Viterbo University

2. Something to Think About Patient Safety should not be a priority in healthcare.

3. Medication Error  Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare professional, patient, or consumer  NCC MERP, as cited in Lehne, 2004

4. Medication Errors Impact Patient Safety  Missed doses  Wrong time of administration  I.V. rate too fast  Wrong concentration or dose delivered I.V.  Wrong route of administration  Missed or mistaken provider orders

5. Nursing Actions Impact Patient Safety  Mis-identification of patient; wrong medication delivered  Documentation of medications before giving to patient  No documentation of changing patient conditions  Lack of attentiveness  Inappropriate judgment

6. Remember When ?  Novice nurse behaviors and actions Nervous and careful with medication administration Provides undivided attention to task Prepares one medication at a time Seeks information about unfamiliar meds Checks patient allergies, weight, lab values Has another double check medications Provides education to patient about meds

7. After Gaining Experience ?  Expert nurse behaviors and actions Prepares IV mixtures, not waiting for pharmacy to prepare Administers medications before pharmacy reviews orders “Borrows” another patient’s meds, to allow quick administration Does not label self-prepared syringes of meds May not take med record to bedside for prns Has unauthorized med “stashes” on unit

8. At-risk Behaviors  Intentional and unsafe practice habits, learned through experience Healthcare providers, insurers, pharmaceutical industry, medical device vendors Engage in at-risk behavior because rewards are often more immediate and positive than the potential for patient harm  ISMP Medication Safety Alert, 2004

9. Sources for At-Risk Behaviors  System-based Unnecessary process complexity  Patient medication in multiple storage areas  Nurse may move meds to more readily accessible area Problems with technology  Repeated waiting for computer terminal access  Physician may resort to verbal orders when prescribing  Pharmacist may skip checking lab values

10. Sources for At-Risk Behaviors  Organizational culture with high tolerance for at-risk behaviors Staff believes more positive rewards than negative rewards for at-risk behavior  “Saves” time now; chance of patient harm viewed as remote and unlikely Staff believes more negative rewards than positive rewards for corresponding safe behavior  Labeled as “slow employee”, rather than “efficient”

11. Areas Involving Potential At-risk Behaviors  Patient information  Drug information  Communication  Labeling, packaging  Drug stock, storage, distribution  Patient education  Staff education  Technology  Environment/ staffing patterns  Quality/culture  Double checks  Teamwork

12. Environment/Staffing  More concern with cost of medication units, rather than safety  Managing multiple priorities while carrying out complex processes  Failure to adequately supervise/orient staff  Inadequate staffing based on patient acuity

13. Quality/Culture  Sacrificing safety for timeliness  Failure to report and share med error information  Organizational culture inspires secrecy instead of openness  Finger-pointing rather than system change

14. Double Check/Teamwork  Failure to perform independent double check thoroughly  Failure to ask colleague to double check medication  Reluctance to consult colleagues for help  Unresponsive to colleague’s request

15. Consider...  Should patient safety be a priority in healthcare? “Priority” implies an order in a list that can be altered according to circumstances  Could this “order” be based on: Demands of the shift or day? Focus of expedience, productivity, efficiency, or cost effectiveness?

16. Case Example  You have had a busy shift and it is now 1400; a new admission has been assigned to you and the patient will arrive soon. Due to family obligations, you must leave the unit at exactly 1500. The 1400 IV medication for one of your other patients is “missing”, so you call the pharmacy.

17. Discussion  Under these circumstances, how would you react to: Pharmacist takes time to fully investigate where the missing medication is located Pharmacist immediately mixes another dose and sends it to you  Priorities?  Which action offers more positive reinforcement?

18. Case Example  It is 0800 and you are engaged in a hectic patient assignment. The physician is writing orders to transfer one of your patients to another nursing unit. The hospital policy states that medication administration records will be reviewed by the physician during the transfer process to avoid unintentional discontinuation of medications.

19. Discussion  Under these circumstances, how would you react if: You are using the medication administration record when the physician wants it The physician elects to not check the medication administration record prior to writing orders  Priorities?  Which action offers more positive reinforcement?

20. Patient Safety as a Value  Link uncompromised patient safety to every healthcare activity  Emphasize specific behaviors which contribute to patient safety  When at-risk behaviors identified: Do not use disciplinary actions Do uncover reasons for using them Conscious risk-taking not involved in all medication errors; prompt for answers

21. References  Institute for Safe Medication Practices. (2004, October 7). ISMP medication safety alert! Retrieved April 17, 2005, from http://www.ismp.org/PDF/At_Risk_behaviors.pdf  Institute for Safe Medication Practices. (2004, October 7). Reducing "at-risk” behaviors. Retrieved April 17, 2005, from http://www.ismp.org/MSAarticles/ReducingPrint.htm  Institute for Safe Medication Practices. (2004, September 23). Why we engage in "at-risk behaviors". Retrieved April 17, 2005, from http://www.ismp.org/MSAarticles/PatientPrint.htm  Lehne, R. A. (2004). Adverse drug reactions and medication errors. Pharmacology for Nursing Care (5th ed., pp. 62-71). St. Louis, MO: Saunders.