Error Prevention Strategies: It's not "Sophie's Choice" folks

Last week on my Medscape medication safety blog On Your Meds, I wrote a piece about how nurses in greater San Francisco area hospitals improved medication safety. The collaborative is reporting an 88% reduction in the incidence of errors in the administration node of the medication use process over a three year period.

At the outset, it's worth noting that these results are astonishing, placing them in the "almost too good to be true" category. The study employed "observed error" methodology, a more robust method of error detection than "reported errors," (the methodology most programs and data sources rely on). The rigor of the detection methodology used in this study adds credence to the results.

But it's worth looking a little more closely at the study design to find the most important take-away lessons.

The nurses tested how adherence to six distinct performance elements in their medication administration process impacted accuracy: [link]

1. Compare medication to medical record
2. Keep medication labeled until administration
3. Check two forms of patient identification
4. Immediately record medication administration in chart
5. Explain the medication to the patient
6. Minimize distractions and disruptions during the administration process

From an engineering standpoint, these elements can be predicted to produce a robust medication administration system. Comparing medications to the medical record and checking two forms of patient identification, for example, add redundancy at high stakes junctures of the process. And "explaining the medication to the patient" creates a recovery opportunity, an engineering control that allows an error that's been set in motion to be detected and remediated before harm occurs. (The practice is also desirable from a participatory care standpoint and also is "the right thing to do" based on variety of ethical principles.)

"Minimizing distractions and disruptions during the medication use process" is the performance element that drew the most attention in the lay press, and it's what I focused on the first time I took on the issue at Medscape. Minimizing distractions at high stakes junctures of performance is a technique that high reliability industries employ. (It's why aviation personnel in the flight deck close the door and why they're subject to tighter performance expectations at altitudes less than 10,000 feet.)

What the San Francisco nurses really studied is whether adherence to a system designed to elicit a specific outcome yields the desired outcome more often than using a loosely defined, variably employed set of expectations does. Minimizing distractions was an important part of the interventions, but it wasn't the only one. The nurses did not find one "magic bullet," but rather moved from an "intention-based" process to a process that was both engineered and adhered to, something that helps explain the very favorable, highly desirable results obtained.

Understanding how these results were obtained is also important before leaping into the comparative arena, especially when the discussion is built around a "forced choice" construct that does not and should not exist. This is what I think is happening in a blog post entitled, Low Tech solution to Med Admin errors better than BCMA?

Designing the most robust system feasible to accomplish a high stakes task is how system engineers approach their work. (Risks surrounding medication administration are well documented and errors at this point remain common.)

Seminal medication safety data show that a substantial portion of errors originate in the administration phase of the medication use process.



Equally important these data reveal that patient harm is highly likely to occur as a result of errors that originate in the administration node.


It's important to recognize that errors in the administration node are problematic, not because nurses are problematic but because the systems nurses rely on and the downstream position of their work confer risk. Managing that risk has been the focus of medication and patient safety specialists over the past decade. IT solutions, specifically the ability to bar code patients and their medications, and to have key patient, drug, and order information integrated and available at the point of care, represent strategies engineers see as reliable, reproducible, and capable of sustaining change over time.

The San Francisco nurses' study did not rely upon bar code medication administration (BCMA) although it appears BCMA was used in at least some of the study sites. But what must be noted is that key performance measures in the study (namely, "compare medications to the medical record" and "check two forms of patient identification") represent standard medication safety practices that are now part of The Joint Commission's healthcare accreditation standards. While they are important elements in the system design the nurses tested, these elements are not "stand alones." They would have occurred, on some level and likely with unwelcome variability, in these hospitals during the study period irrespective of whether they were part of an intervention study.

More important to debunking ill-conceived notions that medication administration accuracy is an "either/or" proposition (pitting low tech performance measures against tech-mediated ones) is the knowledge that BCMA automates key elements of the performance measures the San Francisco nurses built into the system they tested. These include comparing medication to data in the medical record; immediately recording medication administration in the chart; and checking two forms of patient identification. Additionally, BCMA work flows necessarily foster work processes in which medications remain labeled (often in their original packaging) until the point of medication administration.

If BCMA has failed to reach its full potential in the medication administration arena, as John Poikonen questions in his RxInformatics post, the reason has less to do with the inherent fitness of the technology than how user-friendly it is designed to be; how it is incorporated into nurses' work flow; and how it is supported in the aftermath of the initial investment. Most importantly, disappointing results with BCMA likely reflect system design failures that do not take into consideration the limits of human performance when carrying out high stakes tasks. Nurses should rely on automated solutions to accomplish high stakes work and they should not be expected to multitask while using them.

Your pilots get to close the cockpit door when they perform tasks that, if carried out incompletely or incorrectly, could kill the people who depend upon them. Pilots also rely on high tech instrumentation that automates many key performance elements.

Why would you want your nurses to "pick one"?


Note: Representation of the seminal medication error data discussed here was borrowed from similar formats used by the medication safety professionals at the Institute for Safe Medication Practices. I am indebted to them, both for this depiction and the modeling upon which my knowledge of medication safety is based.

Jon and Kate: I think I'll medicate!

Call me silly, but I'm always surprised when highly predictable events happen. Take the high-profile dissolution of Jon and Kate Gosselin's marriage.

Under circumstances that can best be described as childbearing Yahtzee, a young couple in rural Pennsylvania manage to add six-of-a-kind to the deuce they rolled in the first round of play. Shortly thereafter, they score a reality TV series, adding producers, cameramen, photographers, hired help, speaking engagements, investment portfolios, and book tours to the primary task of raising eight humans, six of whom--unfortunately and largely without precedent--share the same developmental stage.

She thrives, leaving the stay-at-home-mom-who-happens-to-drive-a-church-bus image behind and morphing into someone who might be credibly cast on "Real Housewives of Punxsutawney." He begins to resemble Jim Carey in "The Truman Show." The marriage crumbles. Who knew?

Marriage in the U.S. doesn't have great odds to begin with, and marriages with high-order multiples have higher failure rates than others. But like Captain Renault in Casablanca, we're shocked, shocked to find that gambling is going on in here!

The denouement of Jon and Kate has left me thinking about medication use, a topic that could reasonably be expected to arise in an upcoming episode. So, in the short window of clarity that followed the "ah-ha" moment when I learned Jon and Kate ain't great, I jotted down eight things about medication safety that you, too, probably knew all along. (Apparently, we should be shocked, shocked to find that gambling has been going on here!)

1. If you routinely identify patients using 2 distinct identifiers and engage them in the care that's about to occur, you're less likely to give a patient the wrong medicine, conduct the wrong test, or perform the wrong surgery.

2. If you make drug information available to clinicians on the front line (preferably in a mode that's as easy-to-use as an iPhone, not a dogged-eared text from an earlier century), the clinician administering drugs will be able to become familiar with, and actually double check, unfamiliar drugs and doses before administering them.

3. If you say "fifty" (without saying "five-zero") over the telephone, you're likely to be heard to say "fifteen." "I'll be there in 15 (or 50?) minutes" is not as much of a problem as, "Give her 15 (or 50?) units of insulin." Break multiple digit numbers into their simplest form, say and spell drug names, and read back and verify high-stakes information that's transmitted verbally.

4. 1400 commonly used drugs look like or sound like another one. These similarities regularly cause competent people to select an unintended drug from a computerized pick-list or mis-hear a drug as its sound-alike cousin. If you include the purpose for the drug on all orders or written prescriptions, this information allows another knowledgeable professional (like a pharmacist or nurse) to detect and derail a look-alike, sound-alike (LASA) error since few members of LASA drug name pairs are used for the same purpose.

5. If balsamic vinegar and olive oil come in similar containers, it's easy to kill a quesadilla. How drugs are stored at work matters, too.

6. If something can be attached to something else, someone will attach it. Good for tinker toys, Legos, and jigsaw puzzles. Bad for oral medications in parenteral syringes and pressurized B/P tubing connections that are compatible with IV lines. If you can't put diesel fuel into your gas tank by mistake, why don't we have similar safeguards in place at work?

7. If the lighting is bad in a restaurant, you have trouble reading the menu. If the lighting is bad over automated drug dispensing cabinets, your front line is going to have trouble reading the labels of the drugs they remove from them.

8. The average age of a nurse is around 50 years old. Most drugs that are given today were boiling in a cauldron somewhere when we took our boards. If you define how risks associated with high alert medications and LASA drugs are managed in individual care settings within your organization and teach these strategies to nurses (and others who handle drugs), you will prevent mistakes that have been made elsewhere from occurring where you work.

I hope you find these 8 to celebrate, agitate, and advocate, eight things that will help you take care when you medicate!

Do you see what I see?

Everybody likes a good story, and I hope you'll enjoy one about a near-miss medication misadventure as the celebration of nurses and nursing sensibilities continues during Nurses Week 2009. I like this one because it shows that responsive nursing care remains vitally important to achieving safe and accurate medication use. No HIPAA violations will occur here, because this is my story.

I hope you'll be able to see what I see! And if you like reading this story and analyzing the case, ISMP's Nurse Advise-ERR, a free electronic newsletter, can arrive in your e-mail inbox, giving you access to more error reports and ways to reduce risk. Your free subscription can be activated by registering here.

Several years ago I sought care in my local ER for unrelenting chest pain of about 3 days duration and was diagnosed with bilateral pulmonary emboli. (I would strongly discourage others from waiting for three days to have chest pain evaluated, but in keeping with today's theme, I'll just say that hindsight is 20/20.)

In any event, I was fortunate to have had slow-onset pulmonary micro-emboli, the kind that tend to resolve with anti-coagulation, leaving sufferers in good shape on the back side. So from Sunday evening until Friday morning, I became the lowest maintenance inpatient on a busy medical-surgical unit: I had IV access for about 24 hours, received sub-cutaneous enoxaparin (Lovenox) each day, had daily labs and took a warfarin tablet each evening. The hospital had electronic medication administration records (MARs) and bedside bar-code scanning matched me to my electronic MAR and to the medications ordered and dispensed for me.

You should also know that as a L&D nurse, my knowledge of warfarin therapy was relatively limited. By Day 2, I figured out that I was unlikely to die as result of this particular embolitic event (assuming the pulmonologist's statistics were to be believed). And, once the chest pain resolved, I spent most of the week connected to the hospital's wifi catching up on homework. (Being midway through a master's degree, I took survival of an embolitic event as a sure sign that I should finish school.)

Warfarin teaching came to me by way of the nursing staff. I understood the "go home" INR number to be 2 and was pleased on Thursday morning to know that my number was 1.8, close enough to therapeutic that one more pill and one more night in the hospital would likely buy me discharge home.

On Thursday evening, the nurse caring for me--and the computer work station and med cart she pushed--arrived as expected. My armband was scanned, the med was scanned. "Tonight," she said brightly, "You're going to get 2 pills instead of one." "Really?" I said. "Yes," she replied, "one 10 mg and one 7.5 mg."

I reflected. Something about the cheerful announcement made my hard-drive blink. (My personal hard-drive, not the one with my homework flickering on the screen.) But I had no concrete facts at hand. Having been thankful to survive the scary ordeal, I had been a relatively passive patient up until this point. In fact, I didn't even know what my daily dose of warfarin had been.

So I said, "I don't know much about anti-coagulation, but I have a question. Do you usually give someone whose INR is almost therapeutic a big dose of warfarin to push them farther into the range?" My nurse paused. "No," she said. "Do you mind checking?" I asked. "No, I don't mind. No problem. Glad to do that."

When she returned, she told me, "You doctor wants you to have just one: the 7.5 mg tablet," ending my close call with a warfarin overdose.

Professionals who work in a complex system, especially one that crosses disciplines, can usually see risk points (and opportunities for improvement) in their own sphere of influence.




When complex systems of care are analyzed, those closest to the patient are said to be at the "sharp-end." So if you're a nurse or other provider who touches patients, you're there. And when an error occurs, what went wrong at the sharp-end is relatively easy to uncover.

How to prevent reocurrence is more important than who made the biggest mistake. So I encourage you to look at the big picture, focusing on processes, not people. Here are 4 factors that set this error in motion and allowed it to nearly reach me.

1. My physician wrote an ambiguous order. The daily dose of warfarin 10 mg I had been receiving was not discontinued when the prescriber wrote the 7.5 mg dose on Thursday morning. Clear communication of dose, especially when titrating doses of high alert medications like warfarin, is essential. A process for doing this should be meticulously defined and used.


2. My current INR was not available to the pharmacist. Warfarin is titrated based on a patient's therapeutic response (genetic differences influence the way the drug performs and a multitude of other variables make its therapeutic window maddeningly tight). Absent current INRs, pharmacists cannot perform meaningful dose-checking, a vital part of pharmacy practice.


3. A "high dose" alert in the pharmacy computer system was absent or over-ridden. While 17.5 mg of warfarin is a conceivable dose, it's not a typical dose, especially for a new warfarin user who had shown a predictable response to therapy during the initial days of therapy. Alerts in commercial software programs call attention to orders with unusual doses, enabling the pharmacist to review, and when necessary, intervene before a wrong-dose error reaches the patient.


4. My nurse lacked knowledge of the drug dose & how INR values informed the dose. Warfarin is a high alert drug. On a busy medical-surgical unit, validation of knowledge for high alert drugs should be part of initial competency validation. Additionally, readily available drug resources should be available to front line nurses.

Here are 2 factors that saved me from the overdose:

1. Something didn't make sense to me, so I questioned the plan of care. My clinical condition was such that I could self-advocate, and I did.

2. My nurse did not see herself or the system as infallible. When faced with the possibility that something could be amiss, she double-checked. It's important to realize that I likely would have backed down if the nurse had not been so willingly to call the doctor and double check the order.
A shorter version of the story looks like this:





As I've told this story over the years, most people identify the nurse's knowledge deficit as the primary cause of the near-miss. Her knowledge deficit is a disturbing risk point, but, in my mind, no more so than the events that allowed the erroneous dose to be ordered, entered on the MAR, and brought to my bedside. Should the doctor have been able to communicate an unambiguous dose? Yes. Should the pharmacist have recognized an atypical dose and intervened before dispensing it? Yes. Should the nurse have had better knowledge about warfarin dosing? Yes.

Blaming any one person for the hole in their slice of the cheese is futile. System solutions, like "warfarin order strategies that prevent ambiguous doses from reaching an electronic MAR" and "validating nursing knowledge of high alert drugs during initial competency validation," make each hole smaller. Closing any hole works. Closing them upstream works best.

The last thing I'd encourage you to see is that while I may have saved myself, but I couldn't have done it without my nurse! Thanks to all of you, and happy Nurses Week!

Risk points across the medication use system

Recently, Nurse Ausmed shared a great post about an intervention that lessened the likelihood of an IV medication error occuring in a pediatric patient. Her take-away lesson was "simplify, simplify," a core principle in safe medication practices.

Earlier this week, I wrote that Nurse Ausmed's online case study would lend itself to a basic excercise in identifying the latent (or upstream) conditions that often lead to error on the front line. Links to ideas about modeling human error (developed by James Reason) and some online pediatric medication safety resources were provided.

Here are my initial thoughts:

To answer the question, "Could the error-prone condition be identified and the potential for patient harm lessened before it reached the front line?" start by considering what the medication use system looks like:

The roles and responsibilities of professionals ("who does what, when, and how") may vary according to practice setting and applicable professional standards of care. Irrespective of setting, however, prescribing, transcribing, dispensing, administering, and monitoring are the units, or nodes, that make up the medication use system.

It's important to pause for a moment and take this in. As individuals, we typically focus on the portion of the system where our own professional duties lie, rather the system as a whole, making it difficult to see upstream opportunities.

Now consider the problem of errors in the medication use system:

Errors may originate at any point in the process. In the slide below, the red arrow illustrates how an error that began in the prescribing phase is not picked up, moving through all downstream defenses to reach the patient.

Seminal medication safety research shows the likelihood of catching (and correcting) an error increases the further upstream the error originates. This makes sense since an error in the prescriber's order has the potential to be picked up by the person who dispenses the drug, the person who administers the drug, or the patient. This is why processes like independent double checks and automated clinical decision support are valuable: they make errors and error-prone conditions visible before they reach the patient.

Unfortunately, errors that originate in the administration phase are highly unlikely to be picked up before they reach the patient. This is why processes at the point of administration should be as simple, standard, accurate, and dependable as feasible. (I think of clinicians who administer medications and the processes they use as I would a flight crew: it's probably not a good idea to expect problems to be solved at 35,000 feet that could have reasonably been resolved on the ground or to use patchy processes to accomplish high-stakes, in-flight tasks.)

Later next week, I'll come back to this topic, using clinical information Nurse Ausmed shared to help identify strategies for preventing IV medication errors in peds that are on the high end of the risk reduction hierarchy. I'd hope you'll share the risk-reduction strategies you use when you care for pediatric patients.

Stay safe and come back soon! I've been thinking about something I heard Paula Poundstone say last week, and the next time you check in, you need to be ready to laugh!