Opportunities to Reduce Medication Errors

¶ … Opportunities to Reduce Medication Errors

The purpose of the project envisioned herein is to reduce medication errors in the clinical setting with the goal of reducing medication errors by at least 50%. The name of the project, "The Six Rights to Eliminating Medication Errors" (hereinafter alternative "Six Rights") is described in the following report.

It is the goal of the Six Rights project to raise awareness of the adverse outcomes associated with medication errors and to provide clinicians responsible for medication administration with some step-by-step guidelines they can use to achieve zero-level medication error rates.

The projective objectives are to achieve measurable improvements in benchmarked medication error rates during the duration of the project as set forth below:

Clinicians will remember the six rights to reducing medication errors;

Clinicians will understand the six rights to reducing medication errors; and,

Clinicians will apply the six rights to reducing medication errors in their day-to-day activities in statistically demonstrable ways.

Evidence-Based Review of the Literature

Despite ongoing efforts to reduce and eliminate medication errors in the clinical setting, a number of errors continue to be made in their administration (Evans, 2009). The implications of medication errors can be profound, and the weight of the responsibility falls on the nursing staff involved (Revere & Black, 2003). In fact, according to one clinician, "As registered nurses have the responsibility of the final contact with the medication prior to administration, they are often held accountable for subsequent adverse events. Administering a medication is the nursing task that carries the highest risk, and the consequences of an error can be devastating for the patient and the nurse" (Evans, 2009, p. 19).

According to Revere and Black (2003), there are a number of data collection and analytical techniques available that are especially well suited for situations where a nonexistent error rate is the goal. In this regard, Revere and Black emphasize that "[These methods] are ripe for healthcare because many healthcare processes require a near-zero tolerance for mistakes" (p. 37). Moreover, the Failure Mode and Effects Analysis is already required by the Joint Commission, and the process can be easily integrated with current quality assurance methods, making these ongoing efforts more successful as a result (Revere & Black, 2003).

These are highly desirable qualities in a healthcare initiative where resources are already scarce, and where any improvements in error rates translate into enormous potential savings and quality of patient care (Bomba & Land, 2006). In this regard, Mahmood, Chaudbury, and Habib (2009) emphasize that, "Medication errors contribute significantly to patient morbidity and mortality and are associated with a considerable cost to the healthcare system" (p. 119). Despite the universal need for zero-tolerance in medication errors, many healthcare practitioners may not know how to go about achieving such a desirable outcome without some step-by-step guidance to help them focus on a mutual goal. In this regard, Wine and Khanfar (2008) suggest that, "In a hectic work environment without effective guidance to reach any goals to decrease these errors [will] lead down a path of destruction and failure. Real-life medication errors stress the importance of proper management, organization, and personnel unity and cooperation that are necessary to prevent both employee dissatisfaction and patient emergencies" (p. 121). Clearly, any cost-effective initiative that can take advantage of existing resources in innovative ways to reduce medication errors represents a timely and valuable enterprise, but these types of projects can be difficult to come by without some creative thinking.

Because medication errors are already collected in clinical settings in the U.S. that are accredited by the Joint Commission, though, a potentially viable step-by-step approach to reducing medication errors in tertiary healthcare facilities can be achieved using the so-called "six rights to medication administration" described in Table 1 below.

Table 1

Six Rights to Medication Administration

"Right"

Description

The right medication

This involves comparing the medication to the medication order, a step described by one clinician as being "imperative"; in addition, "The administrator must only give medication they have prepared and be present when it is taken."

The right dose

This step requires timely peer review: "To ensure that the right dose is given, the administrator must triple check any calculations and have another team member check the calculation."

The right client

Although ID systems vary, the advice provided by this clinician indicates that, "The administrator must identify the client by checking the medication order and the client's identification bracelet to ensure that the right client is receiving the right medication."

The right route

Likewise, this clinician advises, "The administrator must give the medication via the right route. In preparing the medication, the triple check will identify the route to be given on the medication order."

The right time

Penultimately, double-checking the time is required: "The administrator will check the medication order to ensure that the medication is given at the right time. The prescriber will identify the times that the medication is to be given."

Proper documentation

Finally, clinicians administering medication are responsible for recording the client's status prior to the medication administration as well as the medication given, the time it was given, the dose given, and the route administered. In addition, "Then the administrator will follow up and record the client's response to the medication given."

Source: Adapted from Six Rights to Reducing Medication Errors, 2012

Methodology

The project will consist of a series of custom-designed posters, 11" X 14" (released monthly) and newsletter entries (published weekly) focusing on each of the "six rights" (as described further below). The project leader will emphasize each of these "rights" by visiting clinical treatment areas and personally delivering the posters (which will be colorful and highlight the tenets of each of the rights). As appropriate, newsletter articles can amplify these rights and include additional information as needed.

Resources

The resources needed for this project are minimal as follows:

1. A series of six custom-designed posters highlighting each of the six rights and explaining its implications for healthcare providers. These posters would be designed by the tertiary healthcare facility's graphic aids department or by the project leader depending on expertise level.