07/19/11

TAMPA – When Mara Aronson, RN, started working as director of nursing at the Spaulding Nursing and Therapy Center – North End nursing home in Boston, she noted that a suspiciously small number of drug errors were being reported.

"I suspected that many errors were identified but not reported," she said. A staff survey showed that people were afraid of being punished for "medication events."

The director of nursing worked with facility managers to create a positive attitude about identifying and reporting errors. With staff input, she implemented a new reporting form and created a monthly medication-event newsletter.

Among key messages newsletters have carried:

--Medication errors are caused by people trying to do the right thing.

--Errors should be corrected as early as possible.

--Medication events nearly always have multiple explanations.

--Errors need to be reported to improve systems and decrease the risk of similar events.

--Disciplinary action rarely corrects a problem.

--Hiding or denying a medication event never prevents the next one.

Once a staff member identifies a medication event, management will work with the person to identify and correct the problem, she said in an AMDA annual meeting session.

"We started by stapling this to paychecks," she said. Since then, the newsletter has been posted in nonpublic staff areas and sent via e-mail to all nurses, physicians, nurse practitioners, pharmacists, and registered dietitians. Each newsletter addresses a different topic, determined by medication events in the facility.

Before long, Ms. Aronson said, the facility went from having about one reported medication event a month to one per day. "I was pleased," she said. The higher number of reported medication events didn’t mean that clinical practice suddenly deteriorated, but rather that the facility was doing a better job reporting errors.

Focus on Systems

Taking the focus off individual nurses when errors occur, Ms. Aronson’s team turned to systems issues. For example, they started conducting random monitoring of medical records in search of failures to document p.r.n. drug passes.

They then conducted some education to address the problem, "and in a few months, this documentation increased significantly," Ms. Aronson said. After a while, the p.r.n. documentation numbers went back down, so she and her team sent out a reminder. Now, they are looking to see if p.r.n. medications can be flagged in patients’ electronic records so they can be more closely monitored.

"We can’t have someone looking over clinicians’ shoulders all the time, so we have to rely on a strong med-events process."

Other issues require attention, said Ms. Aronson. For example, labels with conflicting information on a drug’s concentration led to a patient receiving an overdose of a compounded drug. Another case involved a change in a drug’s manufacture and packaging that could have caused a medication error.

Terrence O’Malley, MD, who is the medical director at the Spaulding facility, said that nurses also should watch for and report prescribing errors. He said this can be challenging, as nurses may be hesitant to point out physician errors, "Even when you have a good culture."

Whatever the problem, sometimes a simple change can make a big difference, he said. For example, "we have a simple intervention where nurses can have a ‘zone of silence’ when they are conducting the med pass," so they can focus on the task without distractions.

Ms. Aronson stressed the need for facilities to keep an eye on their medication-event data. Fluctuations in a number over time may suggest a need to remind everyone – not just new nurses and managers – about the importance of reporting errors. Even the best system and staff will not catch all errors, though Ms. Aronson wants to know about as many as she can. CfA

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.

<- Back to: AMDA Annual Conference Highlights