Medication Safety
Sonya Collins
Medication errors are the third leading cause of death in the United States, with an estimated 400,000 hospitalized patients harmed in some way by medication errors every year. Many of these could be avoided through practice changes.
The Institute for Safe Medication Practices (ISMP) has identified the top three medication errors for which health systems should ensure they have preventive policies in place. These errors are not necessarily those that happen most often or that cause the most serious consequences for patients. But rather they could potentially be systematically eliminated.
“We pegged these three because they’re hazards that continue to occur but could be avoided with some practice changes,” said Christina Michalek, BSPharm, director, Membership and Patient Safety Organization, ISMP.
When the barcode won’t scan
Barcode medication administration (BCMA) systems significantly reduce medication errors. But when not used properly, they can introduce medication errors and lead to serious patient harm and sometimes death.
ISMP cites the case of a nurse who inadvertently administered Naturalyte, a liquid acid concentrate that is diluted and then used as a dialysate with hemodialysis equipment, to a patient rather than the prescribed Suprep Bowel Prep Kit.
Unable to scan the barcode on the Naturalyte, which was believed to be the bowel prep, the nurse reported the problem to the pharmacy, which in turn sent a new barcode label to scan. After scanning the new label, the nurse administered the liquid acid concentrate and soon after, the patient died.
The tragedy highlights a couple of concerns around barcodes.
First, the nurse did not correctly interpret the meaning of a barcode that would not scan. “We often see practitioners who think that the barcode just doesn’t work, but the messaging that the system is giving them is that they have the wrong drug, the wrong time, or the wrong patient,” Michalek said.
Second, the pharmacy’s response was inappropriate. “We never recommend that a label be sent without a product attached. We recommend that the product always leave the pharmacy with the label.”
Other unsafe barcode-related practices health systems should strive to eliminate include administering a medication despite the barcode not scanning; scanning after the medication has been administered; and “proxy scanning,” for example, scanning the barcode on a hanging empty bag or a barcode not attached to the actual product being administered.
Running on autopilot with the wrong syringe
Most medications administered in a hospital are delivered intravenously. On the less frequent occasion that a patient requires an oral liquid medication, a provider might dose it using the only syringe on hand—a parenteral syringe. After that, all it takes is a small distraction for the nurse to attach the syringe to the I.V. line and deliver it intravenously.
“All day, for all your patients, say 85% of the time, you’re giving I.V. medications out of a syringe,” Michalek said. “This one time, it’s an oral. What would prevent you from making this error would be oral syringes because they don’t connect to the I.V. line.” This type of error has resulted in serious injury and death.
ISMP recommends that oral liquid medications that do not come in unit dose packaging be dispensed by the pharmacy in an oral syringe or an enteral syringe, such as EnFit, that meets ISO 80369 standards. The health care facility should maintain a sufficient inventory of these syringes in any area where oral liquid medications are administered.
Shortage of drugs, surplus of errors
Shortages can lead to patients receiving less effective care and, in some cases, to objective errors. One in four respondents to an ISMP survey reported they were aware of drugs shortages resulting in at least one medication error. The report cites a case when a patient received double their prescribed medication dose because a pill that was supposed to be cut in half during the shortage was not.
Shortages are unavoidable and it is not feasible to anticipate and plan for each one. But, Michalek stresses, “Health systems have to be nimble.”
Health systems must have a plan in place for how they will address shortages when they arise. The plan must include protocols for determining which product will replace the drug, equipment, or supply in shortage. The plan must also include protocols for standardization, communication, provider education, and monitoring throughout the duration of the shortage.
Low-hanging fruit
By implementing system-wide practice changes related to just these three medication safety concerns, Michalek said, “You’re going to stop these errors from happening. In some cases, you’ll stop them further upstream. In others, at the least, you’ll stop them before they reach the patient.” ■