Your Patient Safety Survival Guide

by Gretchen LeFever Watson

  On a system level, it can be difficult to distinguish a valuable adaptation from a misguided workaround. Once a CPOE system is implemented, hospitals adjust their capabilities, especially by turning off specific system alerts. Some alerts occur so frequently that they run the risk of alert fatigue, which is “caused by excessive numbers of warnings about items such as potentially dangerous drug interactions. As a result, providers may pay less attention to or even ignore some vital alerts, thus limiting these systems’ effectiveness.”45 A review of seventeen studies found that, as of 2006, providers were overriding or ignoring 49 percent to 90 percent of CPOE alerts.46

  While consulting with a healthcare system, a cardiologist convinced the hospital to turn off a commonly occurring drug-interaction alert. He reasoned that he and his colleagues, like all reasonably competent cardiologists, were keenly aware of the risks associated with the particular drug interaction and knew how to manage it safely. The problem was that physicians from other specialties weren’t as aware of such risks or how to handle them, and physicians from the emergency department were using the same drugs with some regularity. After the alert was turned off, two serious safety events, including a death, occurred before the healthcare system realized it needed a broader and multidisciplinary CPOE modification review process.

  As an organization that monitors the safety of CPOE systems postimplementation, Leapfrog has emerged as a leading advocate for establishing standards around leadership oversight and training before, during, and after implementation of new health information technology. Progress has been made in recent years, and it is expected to continue.

  The Human Side of Drug Safety

  The information presented so far should make it apparent just how hard it is to ensure patients receive the right medication and only the right medications. As Gawande explains in The Checklist Manifesto, some four thousand drugs now exist for treating over thirteen thousand diagnostic options, making the process of getting things right both a complex and complicated undertaking. Drug safety is complex because it is not always possible to know the best medications to prescribe. This requires thoughtful decision making that is based on a lot of information that a physician might not have at his or her fingertips or might not have learned. Drug safety is also a complicated process because it requires attention to many details and/or steps.

  A person’s ability to attend and focus, or what is sometimes referred to as a state of mindfulness, has a significant impact on the likelihood of error. Mindfulness is highly variable from one day to the next, and it can shift without a moment’s notice. As noted earlier, nurses are chronically working under conditions that tax their ability to stay focused and concentrate, leaving a wealth of opportunity for error to occur during the medication administration process. So healthcare has developed the concept of the Five Rights of Medication Administration to help nurses cue themselves into being mentally cognizant of their actions when giving medications to patients. The Five Rights refer to the properties listed below.

  1

  Right Patient

  2

  Right Drug

  3

  Right Dose

  4

  Right Route

  5

  Right Time

  The Five Rights of Medication Administration can help catch many of the errors that commonly occur during the medication administration process. However, the Five Rights are intended to be the end goal of the medication process, not the be-all and end-all of medication safety. The Institute for Safe Medication Practices writes this about the Five Rights:

  They are merely broadly stated goals, or desired outcomes, of safe medication practices that offer no procedural guidance on how to achieve these goals. Thus, simply holding healthcare practitioners accountable for giving the right drug to the right patient in the right dose by the right route at the right time fails miserably to ensure medication safety. Adding a sixth, seventh, or eighth right (e.g., right reason, right drug formulation, right line attachment) is not the answer, either.47

  The Five Rights focus on individual performance and not on human factors and system defects that may make completing the tasks difficult or impossible,48 so the Institute for Safe Medication Practices also warns about the danger of engaging in workarounds, even when they don’t result in bad outcomes:

  The healthcare practitioners’ duty is not so much to achieve the five rights, but to follow the procedural rules designed by the organization to produce these outcomes. And if the procedural rules cannot be followed because of system issues, healthcare practitioners also have a duty to report the problem so it can be remedied.49

  Of course, it is equally imperative that those with the authority to make the system changes respond when medication workarounds are identified. Otherwise, providers will continue to use them and place patients at risk. After all, most nurses carry intense workloads and employ workarounds because they seem like practical ways to get the job done—not because they intend to cause harm. When nobody listens to real challenges they face, nurses carry on in the best ways they know how—even if it means disregarding some safeguards.

  No Magic Bullet, But Two Good Habits

  A patient can easily be caught in moments that exist between when workarounds surface and when they are eradicated through systemic hospital improvements. They are also vulnerable to receiving medications in moments when a nurse is distracted. There is no magic bullet to making sure that every patient receives the right medication and only the right medication. At the actual point of medication administration, there is, however, a strategy that can significantly reduce the chance of an error.

  Whenever possible, patients and family members must partner with nurses to make sure that two essential medication safety habits occur: (1) verification of patient identification and (2) a review of our Five Rights. Just like handwashing and time-outs, the general public can learn when these two safety habits should occur and observe whether they do occur because they involve concrete and straightforward actions.

  In chapter 4, I discussed the fallout from improper patient identification before surgeries and other invasive procedures, but the failure to properly identify patients during medical testing, transfusions, the discharging of newborns to families, and the administration of medications also causes problems. The World Health Organization, the Joint Commission, and the Joint Commission International came together to draft a solution to the patient identification problem. Jointly, they advise that, whenever possible, proper patient identification must: (a) actively involve patients in the identification process, (b) begin by asking patients to identify themselves by name, and (c) verify patient identity by at least two pieces of information—usually name and date of birth, which are to be checked against other documentation such as a medication order, medical record, or lab order.50 Furthermore, an in-depth analysis of patient engagement efforts that included patient interviews reported that patients say they are more likely to speak up when providers introduce themselves before treating patients because they equate it with an invitation to participate.51

  As noted above, technology can help avert patient safety mishaps by catching identification errors; however, technology will not eliminate the need for some degree of human checking. During a twenty-month period, 236 voluntary reports were made of wrong patient identification due to missing wristbands and wristbands with incorrect information.52 Even as barcode technology improves, there will still be distinct advantages of verbal confirmation of a patient’s identity. First, technology itself, and the energy source that supports it, can malfunction. Second, the identification process is an opportunity for a momentary patient-nurse interaction that can create a sense of caring—something that helps the healing process and has been corroded since the intro
duction of electronic health records systems and related technologies.

  Asking patients to participate in a review of the Five Rights may seem too complicated, but it isn’t. More importantly, to the extent that nurses embrace the “nothing about me without me” concept, it should seem unfathomable to administer drug therapy to patients without their participation in the Five Rights (whenever patient status allows). Too often, though, nurses walk into patient rooms and change their IV bags or say things like, “I’m just going to give you some medication now” and proceed to deliver medication through existing portals.

  Including patients in the review of drugs they are to be given creates an opportunity for a two-person check. For certain, these would be imperfect, but independent double checks do reduce error substantially. The Institute for Safe Medication Practices reports that, time and again, use of independent double checks has been shown to catch up to 95 percent of errors.53 Nonetheless, nurses and other healthcare providers have resisted routine use of independent double checks because it is incredibly time-consuming to track down another healthcare provider. They also object to heavy reliance on independent double checks because when the process becomes too routine, it is easy to perform it on autopilot—checking without really paying attention to what is written or communicated.

  Having patients participate in the medication checking process does not suffer from either of the sources of resistance associated with independent double checks between two providers, while also conferring additional benefits. First, the amount of time it takes to include patients is miniscule compared to the time it takes to track down another provider. The second person—the patient—is always right there. Second, for patients, the process of double-checking medication will never become as automatic as it is for nurses who must do it every day of their working lives. Also, the patient typically has the greatest investment in getting things right, and the process itself can help patients see that they are part of the healthcare team.

  When patients come to appreciate the importance of these concrete safety behaviors, they will become tolerant, if not outright appreciative, of what may seem to many like annoying and dimwitted redundancies. In the process and without realizing it, people will be acting their way into a new way of thinking about medication safety. Once people are tuned into the magnitude of medication errors and patients start collaborating with nurses on medication administration safety habits, word will spread about errors that were caught and near disasters that were averted. As these scenarios unfold and stories get told, the importance of verifying patient IDs and reviewing drug orders with patients will become understood and reinforced. This safety behavior will become accepted as “just what patients and nurses do.”

  The Special Case of Opiate Painkillers

  I thought about ending this chapter after discussing specific safety habits that can help eliminate medication administration errors. However, the United States is in the throes of a terrifying heroin epidemic that is related to the use of opiates in hospitals and freestanding surgical centers. The problem is seriously threatening the safety of individuals, hospitals, and society. According to the Centers for Disease Control and Prevention, 1.9 million Americans are struggling with addiction to opiate painkillers.

  Several factors are likely to have contributed to the severity of the current prescription drug abuse problem. They include drastic increases in the number of prescriptions written and dispensed, greater social acceptability for using medications for different purposes, and aggressive marketing by pharmaceutical companies. These factors together have helped create the broad “environmental availability” of prescription medications in general and opioid analgesics in particular . . . [which] account for the greatest proportion of the prescription drug abuse problem.54

  The CDC further clarified that some people become addicted to opiates because they fail to take them as prescribed (taking more than the number of pills prescribed at any one time or taking them too frequently) or because they mix them with alcohol and other drugs. However, a small number of people may become addicted even when taking them as prescribed.

  Drug addiction is a complex issue; so what does it have to do with patient safety? The answer: plenty. And if you were to ask Carolyn Weems that question, she would quickly make the connection clear. The strongest risk factor for heroin use is addiction to prescription painkillers—the very class of drugs that are prescribed for over half of American hospital patients. So, who is Carolyn Weems? She is a school board member in the city of Virginia Beach, Virginia—the area of the country where I live—and a mother who recently lost her twenty-one-year-old daughter, Caitlyn. Caitlyn was a much-loved soccer star that suffered a number of sports injuries that required surgery and other treatments. As Weems explains, Caitlyn would get injured, the family would seek treatment for the injuries, and Caitlyn would be prescribed pain medications.55

  Recounting how the properties of pain medications and heroin are virtually identical, Weems refers to Caitlyn’s prescription drugs—Percocet, Vicodin, Dilaudid, Fentanyl, Demerol, and Darvon—as heroin.56 If you’re like me, hearing this for the first time may sound alarmist, but Weems’s perspective turns out to be accurate. Because prescription opiates are not cut with other substances that dealers use to make heroin easier and more lucrative to sell on the streets, prescription opiates actually represent a purer and potentially more addictive form of heroin.

  This problem of heroin addiction stems directly from opiate prescriptions, and it is now affecting people of all races and socioeconomic backgrounds—a phenomenon that is vividly detailed in Dreamland: The True Tale of America’s Opiate Epidemic, a 2015 award-winning book by journalist Sam Quinones.57 Quinones shares the stories of real people whose lives fell from grace as they became unexpectedly addicted to opioid painkillers. When their prescriptions were threatened, many would “doctor shop,” borrow pills from a friend, or buy them on the street or over the Internet. When these options ran out or became too expensive, many turned to the cheap, street alternative—heroin. When the musician Prince died from an accidental overdose in May 2016, his death drew considerable national attention to this epidemic.

  Individuals who have been prescribed an opiate painkiller are forty times more likely to abuse or become dependent on heroin. In 2013, 169,000 Americans became first-time users of heroin. Between 2011 and 2013, heroin use in the United States increased among men and women, most age groups, and all income levels. In the same period, the number of heroin deaths doubled, claiming 120 deaths per day.58

  In 2015, the CDC director summarized the problem this way:

  Heroin use is increasing at an alarming rate in many parts of society, driven by both the prescription opioid epidemic and cheaper, more available heroin. To reverse this trend we need an all-of-society response—to improve opioid prescribing practices to prevent addiction, expand access to effective treatment for those who are addicted, increase use of naloxone to reverse overdoses, and work with law enforcement partners like the DEA to reduce the supply of heroin.59

  To be clear, opiates are essential to modern medicine. Many invasive and surgical procedures could not be performed without them, and they speed the recovery process by enabling patients to more quickly resume normal activities. Although powerful, these drugs can be safely used with most patients; however, getting the dosages properly titrated to a patient’s medical and mental status could be improved with input from patients and family members—because even subtle changes in a patient’s status can affect the safety of opiate drugs.

  Unintended advanced sedation (overdosing) and respiratory distress from opiates can result in insufficient oxygen, pulmonary edema (swelling), hypothermia, and death.

  Effectively managing opiate treatment in hospitals is challenging because how patients respond is influenced by a host of acute medical factors, including the length of time a patient spent under general anesthesia, the presence of other sedati
ng drugs, any surgical incisions that may impair breathing, and the patient’s general state of health. How opiates impact patients is also affected by preexisting conditions, such as sleep disorders, obesity, snoring, pulmonary and cardiac dysfunction or disease, smoking status, and age. Complicating things further, one of the vital signs used to titrate opiate doses is the patient’s report of pain, which is an inherently subjective self-reported measure. A patient’s history of substance abuse and addiction is another nonmedical factor that affects the safety of opiate treatment.

  For a time, hospital use of the drug that brought Josie back from a state of serious oversedation—naloxone—was considered the “cost of doing business.” Today, there is growing appreciation for the idea that the need for naloxone, in and of itself, constitutes a patient safety event. Like healthcare-associated infections, the need for hospitals to use naloxone can no longer be dismissed as a necessary ill.

  Input from patients and patient advocates is centrally important to the safe use of opiates. To a degree, these drugs must be ordered based on the patient-reported felt need for the medications. Because patient input impacts how these drugs are used, they and their lay caregivers must be informed of the potential dangers of these medications, the signs of overdose and dependence, and what to do if they or their loved ones have concerns. With over half of all hospital patients receiving opiate drugs, there is a compelling reason to enlist patients and their lay caregivers in the process of accurately administering and monitoring them.