Patients on adult inpatient medicine units will typically receive medications for several different chronic and acute conditions. Such patients could easily receive fifteen or twenty individual doses of medication administered by three or more different nurses in a single twenty-four-hour period.25
Research suggests that serious drug errors are about as likely to occur when ordered and administered, although they are less likely to occur during the transcription phase.26 Ordering errors often result from insufficient knowledge on the part of providers with prescription privileges—a factor over which patients have essentially no control once they are hospitalized. Patients also have little or no control over errors that are made by a clerk during the process of transcribing a provider’s order or during the process of medications being dispensed to a hospital unit. However, patients can be enormously helpful in eliminating errors during the administration process.
Medication administration errors tend to occur for one of two reasons: first, “silly” and “stupid” mistakes that any of us can make (akin to pouring orange juice in our morning coffee or on our cereal); second, communication breakdowns. Regarding the first common cause: minds are prone to frequent slips and lapses, especially if we are distracted, tired, stressed, or mentally overloaded—the very conditions with which nurses must contend on a daily basis. As summarized in the table below, there are few common sorts of mistakes and factors that contribute to medication administration errors.27
Table 5.1.
Common Sources of Medication Error
Simple Miscalculations
Basic mathematical calculation errors can result in drug errors through careless transposing of units. For example, confusing micrograms and milligrams would result in a patient receiving one thousand times the intended dose of a drug. Misplacing or misreading decimal placements leads to similar types of dosage errors.
Look-Alike, Sound-Alike Drugs
It is easy to confuse drugs with names that look or sound similar to each other. For example, Losec (that treats heartburn, stomach ulcers, and gastroesophageal reflux disease) is known to get confused with Lasix (that treats fluid retention and high blood pressure).
Illegible Handwriting
The problem of poor handwriting is so great that the Joint Commission alerted hospitals and healthcare professionals to the fact that prescriber handwriting is implicated in many drug errors.
Verbal Orders
Verbal orders—regardless of whether they are shared in person or by phone—are more prone to error than handwritten orders. Different accents, dialects, and pronunciations as well as background noise, interruptions, and unfamiliar drug names and terminology often create problems when hearing and interpreting verbal orders. For example, it would be easy to mishear an order for erythromycin instead of azithromycin; an order for Klonopin 0.1 mg instead of clonidine 0.1 mg; or an order for Viscertol rather than Vistaril.
When walking into an unfamiliar unit, juggling a handful of sick patients, or trying to complete all the necessary tasks at the end of a shift, it’s all too easy for anybody to experience a degree of mental overload. To combat information overload, our brains search and sweep the environment until something grabs its attention, and it masterfully fills in the gaps when information is missing. Without realizing it, we direct our attention to what seems like the most salient pieces of information and blot the rest out of our conscious minds. Thus, we routinely act upon a picture that is based on “just a flickering view” of reality. The result is called inattentional blindness—instances when the eyes see what the mind expects rather than what is really there.28
Technology to the Rescue—Yes! (and No!)
Because medication errors are so numerous and a leading cause of healthcare-induced harm,29 the industry has expended considerable effort and resources to develop health information technology (IT) specific to reducing this problem. Three leading health IT interventions include computerized physician order entry (CPOE) systems, barcode medication administration (BCMA) systems, and electronic medical administration record (eMAR) systems.
Computerized physician order entry (CPOE) systems are electronic prescribing systems that intercept errors when they most commonly occur—at the time medications are ordered. With CPOE, physicians enter orders into a computer rather than on paper. Orders are integrated with patient information, including laboratory and prescription data. The order is then automatically checked for potential errors or problems. Specific benefits of CPOE include prompts that warn against the possibility of drug interaction, allergy, or overdose; accurate, current information that helps physicians keep up with new drugs as they are introduced into the market; drug-specific information that eliminates confusion among drug names that sound alike; improved communication between physicians and pharmacists; and reduced healthcare costs due to improved efficiency.30
Recognizing that CPOE systems have a remarkable potential to reduce the rate of error, national healthcare organizations support Leapfrog’s ongoing efforts to drive more hospitals to safely implement and use them. Each year, the number of hospitals using CPOE continues to rise, but “it’s troubling that not all CPOE systems give appropriate warnings for orders that might have tragic consequences for patients.”31 In order to fully meet Leapfrog’s current standards, hospitals must adopt CPOE for at least 75 percent of their medication orders using a CPOE system that includes provider-error prevention strategies and demonstrate their inpatient system can alert physicians to at least half of common, serious prescribing errors. They demonstrate the safety of their systems through a simulation process that has them run mock orders provided by Leapfrog through their systems to see how many known errors their system flags.
The 2014 Leapfrog Hospital Survey results indicated that 34 percent of US hospitals voluntarily completed the annual survey and that over 90 percent of them used CPOE in at least one hospital unit. Fifty-nine percent of Leapfrog-reporting hospitals entered at least 75 percent of their orders electronically. During the testing of the effectiveness of systems used in hospitals that completed the Leapfrog simulation, it was discovered that failure rates remain unacceptably high. During simulation tests, CPOE systems failed to issue a warning on potentially harmful medication orders 36 percent of the time. Further, the number of potentially fatal orders that weren’t flagged by CPOE systems remained above 10 percent, at 13.9 percent.32
Like CPOE, barcode technology has also been useful in reducing, though not eliminating, errors during the drug-dispensing and administration phases.
Barcode medication administration (BCMA) systems are electronic scanning systems that intercept medication errors at the point of administration. When administering medications with BCMA, a nurse scans a barcode on the patient’s wristband to confirm that the patient is the right patient. The nurse then scans a barcode on the medicine to verify that it is the right medication at the right dose, given at the right time by the right route. BCMA is typically used in conjunction with electronic medication administration record (eMAR) systems. An eMAR serves as the communication interface that automatically documents the administration of medication into certified Electronic Health Record (EHR) technology. By linking BCMA with the eMAR, information on medication administration is captured in a much timelier manner than a manual documentation process can accomplish.33
Each of these technological advances—CPOE, eMAR, and BCMA—has the capacity to reduce drug errors in every phase of the process, from ordering to administering medications. Rates of error have been reported for each phase of the hospital medication process. Maximal benefit can be realized by using health information technology systems in a coordinated fashion. For example, both eMAR and BCMA can elimi
nate some medication errors, but using these two systems together increases the capacity to eliminate error. And although routinely using barcodes has proved to be useful in healthcare, they are still only used in about 65 percent of US hospitals. Forthcoming Leapfrog standards will help address BCMA gaps and drive remaining hospitals to implement BCMA and help all hospitals to use BCMA safely.
Table 5.2.
Using Technology to Reduce Drug Errors in Hospitals
Medication Process
Percentage of Errors
Technology
Potential to Avert Errors
Ordering
39%
CPOE
55%
Dispensing
11%
BCMA
67%
Administering
38%
BCMA + eMAR
51%
Another 12% of errors are estimated to occur when a clerk transcribes a physician order, which CPOE has the potential to eliminate. All figures are based on several independent studies presented to the Center for Medication Safety Advancement in October 2012.
Technology is important, but technology alone cannot solve the problem of medication errors; it is never foolproof. Technology is only as good as the systems that support it and the people who use it. Some spectacular CPOE implementation failures forced the industry to accept that CPOE systems are not “plug and play” systems. Since CPOE systems were first introduced, healthcare has learned a lot more about how these systems affect workflow and how to prepare providers for their use. A growing number of hospitals hire outside consulting groups to assist them with training during system go-lives.34 Because healthcare was willing to learn from early CPOE and other technology-related failures, it has improved patient safety.35 But it is also fair to say that too many of the individuals using electronic health information systems on a routine basis remain unaware of inherent system shortcomings and associated risk factors, as exemplified by what happened to a Chicago couple and their newborn.36
Genesis Burkett
Genesis Burkett, a tiny infant, was born to first-time parents who had experienced two previous miscarriages. Although Genesis was born prematurely, he was expected to survive and do well. While being cared for in a neonatal intensive care unit, Genesis received what was supposed to be routine fluid therapy involving a saline solution. He was accidentally administered a dose that was sixty times higher than prescribed. He died soon after this incident. His death resulted from a series of errors that began with the kind of human error that people often make when filling out electronic forms. A pharmacy technician mistakenly typed the wrong information into a computer. Because of the mix-up, an automatic machine dispensed a fluid bag for an adult, ultimately resulting in a massive overdose of sodium chloride. This error was compounded by the fact that the IV mixing machine—that could have identified the problem—did not have the automatic alerts feature turned on. Furthermore, the IV bag’s label did not match its contents and the pharmacist never double-checked the label. To make matters worse, blood tests showed that the baby’s sodium levels were high, so a physician ordered a repeat test; however, a technician assumed the initial lab reading was wrong and the repeat test was never performed. A year after Genesis’s parents filed a lawsuit, the hospital agreed to pay them an $8.25 million settlement.37
The Genesis Burkett tragedy showcases how easily information that is incorrectly entered into an electronic medical system—a decidedly human error—can be perpetuated throughout the delivery care process through the use of technology. It also highlights the dangers of overdependence on technology. In a public statement following the Genesis Burkett case, a spokesperson for the hospital where the event occurred appropriately said:
This event has only heightened our focus on patient care. We have taken comprehensive steps across [the healthcare system] to ensure this type of tragedy does not happen again. The steps include having pharmacists double-check IV bags, making sure that what is on an IV bag reflects what is actually in it.38
Thinking in terms of the Swiss Cheese Model described in chapter 2, the pharmacist made the initial error (human error) that led to the wrong medication being dispensed to the ward (technology-related error). However, once on the ward, the nurse failed to check the label on the medication against the order that was in the patient’s medical record (human error). As noted above, other blunders occurred as well, including a decision not to have the relevant eMAR alert turned on (system issue). A simple slip or lapse of attention—the kind of error that everybody is prone to make on occasion—will sometimes initiate a cascade of errors and set the domino effect into motion. At the end of the day, safety is a people business, and the human factor can never be forgotten. Everyone must play his or her part to maintain safe care.
Overcoming a False Security
As it did for me, perhaps the Genesis Burkett tragedy will remind other behavioral scientists of the infamous Kitty Genovese case. Ms. Genovese was a young woman who was stabbed to death near her home in the Queens borough of New York City. The story made headline news because numerous neighbors witnessed the stabbing, but nobody did anything. While some of the details have been disputed over time, this horrific urban legend prompted many psychologists to study what is now recognized as the bystander apathy or bystander effect. The bystander effect refers to the reality that people are less likely to take action to protect someone when others are around who could also do so. The more bystanders, the more diffused an individual’s sense of responsibility becomes and the less likely it is that anybody will offer help. In one experiment that recreated the Kitty Genovese case, 70 percent of people called out for help when they were alone with a woman in distress while only 40 percent did so when other people were around.39
The field of patient safety has its corollaries to the Kitty Genovese case. It is easy for individual members of the healthcare team to discount the importance of their safety precautions, believing that other known safeguards are in play. Technology is one of those other protective barriers notorious for lulling healthcare professionals into a false sense of security by diffusing the sense of individual responsibility. The existence of error-catching technology can reduce the likelihood that providers will engage in error-prevention safety practices because automated technology that rarely, if ever, gets something wrong minimizes our felt need to be vigilant. And when something doesn’t seem right, we are prone to distrust our own perceptions. So the more contact with technology that alerts people to error, the more ingrained their false sense of security can become.
In a similar way, people sometimes discount their perceptions because of what psychologists refer to as groupthink. It occurs when a group of people becomes cohesive enough that a member of the group becomes reluctant to share contradictory information because he wants to maintain harmony. More succinctly, business writer Megan McArdle calls this groupidity: doing something stupid because other people around you seem to think it is safe.40
Nurses are especially vulnerable to this phenomenon because humans are more likely to take unsafe risks when working in teams or working under pressure—exactly how nurses routinely operate. But so too are more diverse groups of healthcare providers who work in teams and under intense circumstances—like ICU teams that are tight or surgical teams that have worked together for a long time. Unfortunately, the cohesion that helps teams to work together smoothly can also contribute to a sense of overconfidence and lead team members to enga
ge in unacceptable levels of risk, collectively rationalizing away obvious warning signs.41
Unintended Consequences
With workloads that are already barely manageable, whenever a new procedure or policy is introduced, nurses will discover shortcuts to keep moving at their usual pace. When a shortcut is found to work well for one person, with barely a wink or a nod, others pick up the trick. The more people engage in these practices without them being questioned, the more ingrained they become until they are thought of as acceptable workarounds.
A workaround is a method, sometimes used temporarily, for achieving a task or goal when the usual or planned method isn’t working. In information technology, a workaround is often used to overcome hardware, programming, or communication problems. Once a problem is fixed, a workaround is usually abandoned.42
For example, when barcoding is used properly, additional time is required to appropriately scan every medication dose and patient wristband at the patient’s bedside. Because medication administration has been noted to occupy up to one-third of work time among hospital nurses,43 it is a natural target for timesaving workarounds. One study documented fifteen types of barcoding workarounds. For example, when barcoding was introduced on hospital wards, nurses were observed affixing patient identification barcodes to computer carts, scanners, doorjambs, and their personal clothing and to carry several patients’ prescanned medications on carts as they moved between patient rooms.44 Some nurses were seen cutting the bands off patients’ wrists to avoid needing to be with the patient when entering information into an eMAR system. For the same reason and to the same ill effect, when there aren’t enough medication dispensing machines (cabinets that provide computer-controlled storage, dispensing, and tracking capabilities), nurses have been known to stockpile unused medications and “borrow” them to give to another patient when in a hurry. They also saved time by removing medications for multiple patients while the cabinet was open for only one patient and grabbing multiple doses at once.
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