By CS Copeland, PhD
In 2016, Johns Hopkins researchers Martin Makary and Michael Daniel released a groundbreaking analysis pinpointing medical errors as the third leading cause of death in the United States. Spurred by these findings, the Joint Commission, a nonprofit that accredits and certifies U.S. healthcare organizations, has sought to address the problem though establishment of the National Patient Safety Goals, a set of specific goals that aim to improve patient safety. Each goal identifies an important factor in patient safety and provides practical guidelines for achieving that goal. Among the first of these goals is to improve the safety of using medications.
Medication-Associated Errors and Hospitals
Adverse events related to medication are responsible for a large number of hospital admissions, lengthened hospital stays and higher costs. According to a review by U.K. researchers Keers et al., medication administration errors are common, and a significant portion of these are associated with harm or potential harm. Further, the researchers assert that, while nurses are often blamed for errors (since they are the last in the chain of drug administration), most errors could have been prevented by improving the delivery system. For example, a large number of errors are due to “slips and lapses,” many of which could be prevented by forethought, such as using clear labeling (including legible handwriting) to prevent the misidentification of medication or patients. Many other problems can be attributed directly to conditions within a healthcare facility, such as poorly designed equipment, lack of access to drug charts or deteriorated or unavailable medication. A large number of errors are due to hospital policies, including staff exhaustion from long hours without breaks for food, inadequate training and poor supervision. Overly heavy workloads and long shifts are particularly strong contributing factors.
Once staffing is adequate, the best way to lower the number of adverse drug events is to improve the system in which drug delivery takes place. However, this does not mean simply “throwing technology at the problem.” Technology needs to be thoughtfully designed and implemented in the context of the whole system, including hospital culture. For example, using barcodes for medication identification can prevent errors, with one large study finding an eye-opening 41.4 percent overall reduction in medication errors. However, it is important to adopt technology in a careful way, in consultation with professionals with expertise in the area, as this practice can also introduce “side effects” that stem from poorly designed incorporation of technology into workflow.
Clear Goals Towards the Prevention of Medication-Associated Errors
One of the most important steps in creating thoughtfully designed systems to prevent medication errors is to build improvements around clear goals. The Joint Commission has identified three clear subgoals within its main goal of improving the safety of medications. These are: (1) labeling of all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings; (2) reduction of the likelihood of patient harm associated with the use of anticoagulant therapy; and (3) maintenance and communication of accurate patient medication information.
The first subgoal is to label all medications, medication containers and other solutions on and off the sterile field in perioperative and other procedural settings. Serious errors can result when medications or solutions are moved from their original containers into new containers. Yet, this is a routine practice in many hospitals. The Joint Commission has therefore recommended that all medications not in immediate use be kept in clearly labeled containers, including medications transferred from their original container—if any medication or solution is transferred to a new container, the new container must be clearly labeled. Medication or solution labels should include:
Medication or solution name
Amount of medication or solution containing medication (if not apparent from the container)
Diluent name and volume (if not apparent from the container)
Expiration date when not used within 24 hours
Expiration time when expiration occurs in less than 24 hours
Medication should be labeled as soon as it is prepared, unless it is administered immediately. Also, whenever the person administering the medication did not prepare it, medication labels should be verified verbally and visually by two qualified professionals. Finally, any unlabeled medications should be discarded, and at the end of a procedure, all labeled containers should be removed from the sterile field and their contents discarded.
Reduce Risks Associated With the Use of Anticoagulant Therapy
Anticoagulation medications, used for conditions such as atrial fibrillation, deep vein thrombosis, pulmonary embolism and mechanical heart valve implants, are more likely than other types of medication to cause harm. This is because dosing is complex, with a need for regular international normalized ratio (INR) monitoring. Patient compliance is also an issue; patient education and involvement can reduce the risk of adverse events associated with common anticoagulants including heparin, low molecular weight heparin and warfarin.
Specific recommendations by the Joint Commission include using only oral unit-dose products, prefilled syringes or premixed infusion bags (and, for pediatric patients, only products specifically designed for children) when these types of products are available, and using approved protocols for the initiation and maintenance of anticoagulant therapy.
For warfarin, the patient’s coagulation status should be assessed before beginning therapy. Then, during therapy, the INR should be regularly monitored and the dosage adjusted on the basis of the INR assessment results. Food and drug interactions must also be carefully managed for warfarin patients. For heparin, programmable pumps should be used for continuous intravenous administration. For all anticoagulants, a written policy should address required baseline and ongoing lab tests. In addition, safety practices should be evaluated, and action taken to improve practices. Then, the effectiveness of these actions, in turn, should also be evaluated.
Patient education is particularly important when it comes to anticoagulant therapy. Patient and family education should include:
The importance of follow-up monitoring
The importance of compliance
Adverse drug reactions and interactions
Maintain and Communicate Accurate Patient Medication Information
Good communication is key to preventing many medication-associated errors, and it is becoming even more important as patients increasingly use multiple medications. Physicians should consider the medications a patient is taking, as well as their dose, frequency, route of administration and purpose. One of the new recommendations within the safety goals is informing patients of the importance of updated information on the medications they are taking. Medications ordered for a patient should be compared with the list of medications the patient has brought, in order to resolve any discrepancies. Before leaving, the patient (or a family member) should be given a written list of the medications to take after leaving the hospital. Also, the importance of managing medication information should be explained to the patient, including instructing the patient to provide a copy of the list to his or her primary care physician, and to inform the physician whenever the patient discontinues any medication, changes dose, or starts taking any new medications (including over-the-counter products).
Teamwork Towards Medication Safety
The National Patient Safety Goals will work only if implemented thoughtfully, in the context of a culture committed to improving patient safety. This requires all players to work together as a healthcare team. Towards this end, new strategies need to be approached in a way that supports all team members, from the beginning to the end of the drug delivery chain, with the patient considered the last link in the chain. For instance, if barcoding is adopted, it is important to keep readable labels (in English as well as the patient’s native language if it is not English) on the medication, so patients or anyone in the healthcare delivery chain without a scanner can still see what medication is in the container.
Above all, any changes should be accompanied by monitoring and analysis to make sure improvements are working as planned. Any pitfalls—including team members feeling encumbered or burdened by technology rather than being helped by it—can be addressed if monitoring is built into the system. The best strategies for patient safety will improve healthcare delivery not just from the point of view of the patient but also from the points of view of all members of the healthcare team.
Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.