Prevention and Reporting of Medication Errors

The public health problem of death and serious harm resulting from medication errors has gained national attention. Researchers have estimated that almost 50% of drug errors are preventable. An error that reaches the patient is frequently the end result of multiple breakdowns throughout the healthcare system. Preventing errors requires the redesigning of the medical system at all levels to make it safer. Nurses play a key role in the drug administration process and therefore must take an active role in preventing medication errors. Oncology nurses, as members of the healthcare team, must take an active role in addressing the prevention of medication errors.

Data support that more medication errors occur than are reported each year. This underreporting has been attributed to punitive consequences invoked by organizations against individuals instead of systems. Nonpunitive and confidential voluntary reporting programs tend to provide more useful information about errors and their causes than mandatory reporting programs. Medical error reporting is critical in the identification of system deficiencies that can be corrected to prevent future errors. Practitioners who are forced to report errors are less likely to provide the depth of information needed as their motivation may be adherence to a requirement, not necessarily to help others minimize or prevent future errors. The fundamental purpose of a reporting system for medical errors should be to learn how to improve the healthcare delivery process to prevent such errors.

It Is the Position of ONS That

• Institutions and state and national organizations must provide ongoing education to employees and members regarding medication errors and ways known to prevent errors.
• Nursing licensing and certifying bodies must incorporate questions on their licensing and certification exams to ensure professional competencies related to the prevention of medication errors.
• Healthcare facilities and agencies must provide education for the public regarding the role of the patient in preventing medication errors. Each institution also should inform the public that it serves of the programs it has in place to prevent errors.
• Computerized technology related to medication ordering, dispensing, and administration must be developed that addresses the unique needs of the patient with cancer. Continued monitoring of the use of such technology in preventing errors must be maintained.
• Oncology care settings must standardize the kinds of equipment used for the administration of medications to patients with cancer (e.g., volumetric infusion pumps). In addition, equipment with safety features must be used (e.g., free-flow prevention).
• Pharmacists must be consulted for their valuable expertise and should be included in patient care rounds.
• Patient information must be available at the site of patient care.
• Healthcare practitioners and institutions must develop systematic processes for identifying and reviewing medication errors. These processes must be supported from the practitioner caring for patients to the top administrator. Punitive actions within these processes must be eliminated to allow the openness of discussion regarding the errors, with the ultimate goal of establishing the safest system possible.
• Systems for analyzing medication errors must be established within each healthcare institution and care setting at the state and national levels. Collaborative efforts between institutions, states, and agencies should be maximized to optimize this analysis process and to develop comprehensive systems for preventing errors.
• Voluntary error reporting must be established as the national standard. This system must be nonpunitive, focus on the prevention of medical errors, and establish confidentiality as an absolute standard. The primary goal of such a system should be the improvement and enhancement of patient safety.
• Federal protections of individuals reporting medication errors would strengthen the ability to collect a comprehensive and solution-oriented database. Federal law, although necessary to ensure protection associated with national reporting systems, should not preempt state evidentiary laws that provide greater protections.
• Research related to measures to effectively reduce medication errors must be supported, with the ultimate goal of fostering improvement in patient safety.

Background

In the early 1990s, the oncology community began to review the processes associated with the administration of chemotherapy. The Joint Commission on Accreditation of Healthcare Organizations requires the presence of a system to evaluate medication adverse events and errors. In 1999, the Institute of Medicine (IOM) published its report To Err is Human: Building a Safer Health System. IOM has recommended that Congress establish a Center for Patient Safety that would address research issues important to learning more about enhancing patient safety within the United States. In February 2000, President Clinton announced the formation of such a center. Further, IOM states that the federal government should mandate that hospitals and other health facilities report all serious mistakes to state officials to help detect problems, in addition to periodic reexamination of healthcare practitioners and standardization of medical equipment.

Shortly after the release of the IOM report, legislators began writing national legislation to address medical error reporting. Although some states have required reporting of errors that cause specific levels of injury, this is not a universal requirement. Opinions vary regarding the usefulness of mandatory reporting, and, unfortunately, many healthcare practitioners, institutions, and licensing boards still advocate for a punitive approach to address medication errors. Practitioners who are forced to report errors are less likely to provide the depth of information required to fully assess the occurrence of an error as their motivation may be adherence to a requirement, not necessarily to help others avoid the same mistake.

Multiple organizations, both local and national, have begun to look at medical errors in a more systematic method since the IOM report. In September 2000, the Agency for Healthcare Research and Quality held the First National Summit on Medical Errors and Patient Safety in Washington, DC. The purpose of the summit was to focus on the key research questions that must be answered to foster improvements in patient safety throughout the nation's healthcare system and ideas on the approaches that should be taken to answer those questions. Overall, the summit reviewed the information needs of individuals and organizations attempting to improve patient safety, assess the current state of medical errors and patient safety research, and gather information to support the development of a coordinated research agenda. This information is critical for the identification of system deficiencies that can be corrected to prevent future errors.

Medical errors are a complex issue and can occur as a result of a variety of factors within the healthcare system. The majority of medication errors result from unsafe system rather than individual incompetence. Healthcare systems have downsized, restructured, and reorganized to the point where processes initially put in place to protect the public have begun to break down. The impact of inadequate staffing and mandatory overtime on the potential for medication errors is of high concern to nurses. Nurses are key to the delivery of safe, high-quality care and should have an active voice in defining and shaping systems that reduce the likelihood for medical errors and lead to quality outcomes for patients.

Reference

Institute of Medicine. (1999). To err is human: Building a safer health system. Washington, DC: Academy Press.

ONS Board of Directors Approved October 2000; Revised June 2002.