Medication errors account for over 98,000 deaths per year and are a very large part of health care costs.12 It is estimated that preventable adverse reactions account for more than 3.5 billion dollars annually for hospitals.12 The Institute of Medicine report To Err is Human: Building a Safer Health Care System revealed the seriousness of these errors and found that most were preventable.13 Dosing errors are the most common form of medication errors. Other errors occur during ordering and administration and often include the wrong dose, wrong prescription, allergy, wrong time, wrong route, or missed dose. Although several reasons have been found for the error’s communication has been shown to be a common thread.
Another area of concern is that of handoffs or transitions. As continuity of care is disrupted, the risk for error is higher. This can happen with changes of providers such as shift change or when the patient is moved to a different facility or unit. Communication is again the key component. The Joint Commission National Patient Safety Goals requires a standardized handoff procedure include discussion of patient information. As several errors can occur during handoff including, background noise, inconsistent information, incomplete care responsibility, conflicting communication needs and expectations, and inability to listen.13
Handoff tools such as SBAR (Situation, Background, Assessment, Recommendation) are a way to standardize the information that is passed between providers and facilities.13 The situation is described and includes present illness, and reason for transfer, contact information of referring provider, and patient identification. Background information includes diagnosis, past medication history, surgical history, medications, allergies, vital signs, laboratory results, code status, significant events during hospitalization, physical exam findings. The assessment is patient-centered and includes patient-specific needs, concerns, cardiovascular stability, complications, and cultural factors. The recommendation includes information pertaining to the treatment plan, discharge plan, and case management.13
There are also more specific tools for intrahospital transfers (The Ticket Ride Tool) and surgical tools (Postoperative Handover Assessment Tool) for example. Other information can also be included for specific purposes such as mental examinations, barriers, diet, or required patient positioning.12
Nurses find themselves as the last link in the chain of medication management. Nurses are habitually blamed for medication errors when in fact there are multiple people and tasks involved in medication errors, and most medication errors are discovered by nurses.15 Studies reveal that several factors are involved in medication errors that can lead to adverse reaction and sentinel events. Causes identified specifically to nursing care are unsafe practices, misidentification of the patient or medication, lack of knowledge, violation of policy and procedures, calculation errors, faulty checking procedures, equipment deficits, and not following medication directions.15
The use of technology in medication administration has been somewhat successful in reducing medication errors. Barcoding medication for administration, computerized order entry, education, and electronic medication distribution systems have been helpful to nurses and other health care staff in catching and reducing medication errors.
Automation in pharmacy and nursing unit medication dispensing appears to decrease the number of medication errors. The evidence to support a computerized entry system as the ideal way to decrease medication error is marginal at best.13 Nevertheless, health care systems have moved to a more automated method of patient care including computerized order entry, automated clinical decision support systems, and electronic health records.17 Barcoding systems for medication administration help to identify the right patient, medication, dose, route, and time. This system has lowered the errors that occur in the administration phase15. However, the transcription phase must be correct for the barcode to be effective.
Some physicians' orders are still handwritten and then manually transcribed to a medication administration record. This leaves a lot of opportunity for errors. A computerized physician order entry, in which the physician must enter all orders by computer, eliminates handwriting and transcription errors but still may not reduce administration errors13,17 It also makes it possible to automatically check doses, medication interactions, allergies and significant patient data, like impaired renal function. Automation is very dependent upon each phase being correct. If one step is missed or is incorrect due to human inaccuracy, the risk of an adverse effect due to a medication error is significantly increased.
Automated systems can present several problems. There is a significant expense that smaller facilities may not be able to afford. Cost prohibitions or lack of space may limit the number of PCs to the point that practitioners have long wait times for computer access. It also seems slow and inconvenient at times. In addition, physicians who are less computer savvy may be resistant to implement the system fully. Human error is also a factor. Education and communication are again the keys to decreasing medication errors.
