The Alphabet Soup of Med Errors from A to I --How to Collaborate to Decrease Errors

Saturday, 16 November 2013

Bush Rita, MSN, BSN, CCRN, NE-BC1
Jane Janssen, BSN, MBA2
Glenda Pietryga, PharmD2
(1)Critical Care/Cardiology, Bronson Methodist Hospital, Kalamazoo, MI
(2)Bronson Methodist Hospital, Kalamazoo, MI

Learning Objective 1: The learner will be able to demonstrate the value of weekly Medication Safety meetings with leaders to review and learn from issues with medication errors.

Learning Objective 2: The learner will be able to demonstrate an understanding of the value of collaborating with partners in the health system to improve process issues.

Medication errors are multifaceted and can happen at any point in the preparation and delivery process. The Institute of Medicine (IOM) 2006 Report Preventing Medication Errors highlighted that 380,000 preventable adverse drug events take place each year in hospitals.  Weekly Medication Error Meetings that nursing and pharmacy managers attend assist in decreasing the errors that reach the patient and help with identifying institution system process changes. Managers receive information regarding each medication error via the online incident reporting system. Managers review the error, educate staff, remediate staff, and look for system opportunities with 48 hours of receiving the report. Each Friday the CNO leads the nursing/pharmacy leadership group in a discussion of lessons learned from reports and looks for system opportunities for improvement.  Managers in attendance give three pieces of information  to assist in looking for trends: 1. How long has the staff member been a nurse/pharmacist 2.  How many hours into their shift did the error occur 3. How many shifts in a row have they worked. Two system changes thus far have occurred from trends identified.  Pharmacists’ hours were decreased to 8 hour shifts. New graduate nurses no longer allowed to “override” any medication without a co-sign from a Registered Nurse to provide for education and patient safety. Overall the percentage of system medication errors reported decreased 15% from 2011-2012-those with a severity code of C-F decreased from 85% to 81%-near misses reported or category A-B reports increased from 14%-18%. Collaborating with a multidisciplinary team that meets weekly has improved our A-I error reporting process and assisted us to more quickly identify and make needed system changes.