Managers may soon see pressure grow to reduce medication errors in ICUs
Managers may soon see pressure grow to reduce medication errors in ICUs
Regulators may require more self-reporting of adverse drug events
How bad is your record on medication errors? A number of regulatory agencies are interested in knowing. One agency, the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which sets operating standards for the nation’s hospitals, is likely to ask pointed questions about adverse drug events (ADEs) and other issues involving care in your ICU.
The Health Care Financing Administration, the federal agency that administers Medicaid and Medicare, and state and local licensing agencies may follow suit.
It’s all part of a growing trend focused on tightening hospital oversight that for many acute and critical care providers is likely to make ADEs and other sentinel events a hot topic in coming months.
The trend comes in the wake of a toughly worded report from the U.S. Department of Health and Human Services (HHS) in July criticizing the way JCAHO has done its job in monitoring the nation’s 5,000 hospitals.
The upshot of the report is that JCAHO, based in Oakbrook Terrace, IL, hasn’t been demanding enough in its accreditation oversight.
In some cases, it’s been too forgiving with problem hospitals and allegedly has been more "collegial" as opposed to "regulatory" in its methods, the report asserts.
With regard to medication errors, the trend is likely to focus more attention on the whys and hows behind ADEs. Unit nursing managers are likely to be held more accountable than ever for demonstrating their effectiveness in reporting, analyzing, and attempting to reduce their error rates.
While ICUs don’t necessarily take first prize over other departments in reported ADEs, they are among the first places regulators are likely to look for problems with medications.
The reason is the ICU’s high patient acuity, the complex drugs physicians routinely order there, and the growing reliance by nurses and other staff on complex technologies, says Jeanette Ives Erickson, RN, MS, senior vice president of patient care services at Massachusetts General Hospital in Boston.
For more than a year, JCAHO has encouraged providers to increase self-reporting and supported a non-punitive, problem-solving stance when reporting medication errors to its department of standards.
The purpose behind investigating and reporting ADEs to the JCAHO hasn’t been to lay blame or punish, but to analyze causes and foster efforts at reducing the problem, according to a 1998 policy statement issued by the agency. (The chart on p. 99 shows examples of the agency’s reportable and nonreportable events.)
The underlying purpose has been to encourage providers to freely report incidents more often and accurately. By reporting more incidents, officials say problems can be better studied and reduced.
But whether the agency maintains its current position in view of the recent HHS criticism remains to be seen.
It’s been widely known that medication errors originate from a variety of sources within a hospital. Misspellings of drug names by physicians, incorrect dosages, pharmacist errors, lack of internal checks and balances, and technological snafus are chief among them, says Erickson.
Studies show self-reporting cuts ADEs
Studies also have suggested practical ways to prevent ADEs by encouraging self-reporting, conducting daily reviews of patient charts, and classifying events as either ADEs or potential ADEs.1
But whether providers are doing a good job at preventing or reducing incidents of medication error hasn’t been accurately determined. One reason is that hospitals and ICUs have not been good in general about reporting events, experts say.
The push now is to encourage more self-reporting and monitoring of any progress in error reduction efforts, says Kathy Cullen, RN, MSN, nurse manager of the 28-bed post-anesthesia care unit at Mass General.
As in preparing for any certification site visit, you want to show the surveyor or internal hospital administration strong evidence of compliance with high standards, says Erickson. Growing concerns have centered on keeping accurate records for reporting purposes.
ADE documentation reveals weaknesses
One hospital that has taken a simple and direct approach in both reporting and monitoring ADEs has been Our Lady of the Lake Regional Medical Center (OLOL) in Baton Rouge, LA.
The hospital recently introduced two ADE incident reports that cover most of the ground on regulatory compliance, but emphasize ease of use and comprehensiveness. (Samples of the forms are inserted in this issue.)
Being able to produce documentation that tracks each instance and its suspected root cause can reveal important weaknesses in the system, says Rebecca Hedglin, RN, nurse manager of a 12-bed surgical ICU at OLOL.
But the effort comes with a price, adds Hedglin. The creation of the incident reports has more than doubled the amount of paperwork for managers since its inception earlier this year because the staff is now encouraged to report ADEs when they occur without fear of reprisals, says Hedglin.
"That’s what you want, more reported incidents that will give you sufficient information to investigate causes," says Patricia Staten, RN, MS, JCAHO’s Department of Standards associate director.
You will also need some essential facts. These should be included on the incident reporting form and should be clearly noted by your reporting staff in detail. For example:
• Type of error
The range of choices should include unauthorized drugs, omissions, or extra dosages. But information should be as specific as to include whether the wrong dosage constituted an extra dose, the wrong drug delivery route (by mouth, intravenously, etc.), or an incorrect medication preparation.
• Origin of the error
The area of the system the problem occurred narrows the field when investigating the root causes of an error, says Hedglin. Was the order not properly transcribed or not transcribed at all by unit clerks? Was it a charting error? Was the exact medication ordered not available and a close alternative selected?
• Patient reaction
The aftermath of the error needs reporting. The OLOL form gives the information in a yes or no form. As a result of the ADE, was increased patient monitoring needed? Did vital signs change? Were additional lab work or other treatment interventions necessary and delivered?
The information should include a detailed narrative of patient outcome to the additional intervention and an explanation to any yes answers.
• Source demographics
Where or with whom did the problem arise — a physician, resident, or nurse practitioner? Did the problem originate in dispensing? Was it a pharmacist, technician, or the automated medication dispensing or order-entry system?
Perhaps, the error occurred with a float nurse. The manager will have to track down that nurse, who may be working in another department or hospital following the event. All these possibilities should be reflected on the incident form.
• Narrative information
Somewhere on the form there should be space for a detailed narrative of what occurred given by the individual involved in the incident. There also should be a detailed description of interventions taken with a full explanation of the reasons any action was or wasn’t taken.
The name and signature of the person making out the report should appear along with a supervisor’s name, and the time and date of the report.
A final caveat suggested by Hedglin: The incident report should be considered a legal document, but it should under no circumstances become a permanent part of the patient’s medical record and should not be photocopied or distributed to unauthorized hospital staff or outsiders.
Getting staff to comply may appear daunting to a manager. But role modeling works extremely well, suggests Ann Quealy, RN, MSN, nurse manager of the medical ICU at Mass General. "It only has to happen once, and everyone will buy into the unit’s non-retaliation policy," Quealy says.
[Editor’s note: For a copy of the U.S. Department of Health and Human Services’ report, "External review of hospital quality," contact HHS on the Web at: www.os.dhhs.gov/oig, or the U.S. Department of Health and Human Services using a search engine. To report a sentinel event, contact the Joint Commission on Accreditation of Health Care Organization’s Sentinel Event Hotline at: (630) 792-3700.]
Reference
1. Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients: A comparative study of intensive care and general care units. Crit Care Med 1997; 25:1,289-1,297.
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