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You must take steps to spot potential errors before they occur, says Cheryl Pinney, RN, BSN, MBA, director of emergency services at Cheshire Medical Center in Keene, NH, and the hospital’s Joint Commission coordinator. "We need to eliminate the punitive approach’ to medication errors," she urges. Here are some ways to prevent errors:
— Audit use of patient identification bracelets. At Tallahassee (FL) Memorial Hospital’s ED, a quarterly patient identification audit in all patient care areas ensures that the right task is done for the right patient, reports Cindy Bruns, RN, BSN, CEN, quality management coordinator for the emergency center.
Various hospital staff members are used as auditors, with the goal of auditing "10% of a day’s work," says Bruns. "We audit 10% of the average daily patient population for each department. No one audits his or her own department." For example, Bruns is assigned to the radiology department where she answers the following four questions:
1. Does the patient have an identification bracelet on when the patient arrives in the radiology department?
2. When the patient doesn’t have a patient identification bracelet, is central registration or the emergency center notified and nothing further done with the patient until an identification bracelet is on?
3. Does the staff member ask the patient to state his/her full name?
4. Does the staff member check the patient identification bracelet against the face sheet/requisition or physician’s order prior to performing the procedure or medicating the patient?
In the ED, the audit is done in the triage, registration, and treatment areas, Bruns notes. "I can honestly say that ED patients without an identification bracelet are a rare breed these days," she says.
— Review care of high-risk patients. Ideally, auditing of high-risk patients should be done by chart review and follow-up phone calls, says Bruns. "Unfortunately, staffing doesn’t always permit this, especially in these days of patient overload and chronic staff shortages," she adds. "So most of our auditing is done by retrospective chart review."
For example, charts of patients who have received conscious sedation in the ED are reviewed monthly for appropriateness of care and monitoring during conscious sedation, Bruns explains. "All nurses get individual feedback on their care via the completed quality assurance monitoring tool," she says. Chart audits are helpful in showing trends in nursing care and procedures to identify staff education needs, Bruns notes.
— Implement an anonymous reporting system. At Cheshire Medical Center’s ED, a medication error reporting system was implemented. A pad of forms is placed in the clinical areas for nurses to report actual or potential errors. (To see Cheshire’s Medication Event form, click here.) "There is a small box with a slot that the staff member uses to places the completed form in the box," says Pinney. The first month the system was started, four times as many potential or actual errors were reported, she notes.
Staff are encouraged to report potential for error and can remain anonymous if they wish, says Pinney. "For example, a nurse may report two similar-looking vials in the same location or similar labels on very different medications," she explains.
— Track actual errors with occurrence reports. Tracking actual errors helps you identify problems, and you can trend the data to identify ways to improve the system, says Pinney. She recommends including the following on an occurrence report:
— Take specific steps to respond to problems reported by staff. When a "near miss" or adverse outcome occurs due to an error, but not necessarily of the magnitude of a sentinel event, an intense evaluation of the process will help to identify system problems so a similar situation does not occur, says Pinney. She recommends following the Joint Commission’s "Framework for a Root Cause Analysis." (From the Joint Commission web site [www.jcaho.org], click on "Patient Safety/Sentinel events" on the left-hand side of screen, then under "Facts About Patient Safety," scroll down to the bottom of the text and click on "Sentinel Events." Then click on "Framework for Conducting a Root Cause Analysis.")
If anyone reports a potential risk to Pinney, she first notifies the hospital’s risk manager. "The risk manager and I then review the report and see what needs to be done as a next step," she says. Pinney also thanks the employee for bringing the problem to her attention and reports what the next steps will be.
— Be approachable. ED staff at Cheshire are encouraged to come forward with information about a potentially unsafe situation, Pinney says. "They also know that they can call me and/or the risk manager anytime there is a question of a risk situation," she adds.
If a group is later organized to address the problem, be sure to include the employee who first brought it to your attention, Pinney advises. "The manager has to understand that errors are often caused by system problems, instead of assuming that errors are always somebody’s fault," she notes.
For more information about preventing medication errors, contact Cindy Bruns, RN, BSN, CEN, Emergency Center, Tallahassee Memorial Hospital, 1300 Miccosukee Road, Tallahassee, FL 32308. Telephone: (850) 431-5079. Fax: (850) 431-6537. E-mail: BRUNS-C@mail.tmh.org.