Reports spotlight medication errors: Make changes before tragedy strikes
Reports spotlight medication errors: Make changes before tragedy strikes
ED is at higher risk for medication errors than any other area of hospital
When a 6-year-old boy was taken to a local ED after falling from the bleacher seats at a sports event, he developed seizures from his head injury. A dose of Cerebryx was ordered to control the seizures, and the child’s dose was calculated as 300 mg. Suddenly, the child went into cardiac arrest. After unsuccessful resuscitation, it was discovered that 3,000 mg of Cerebryx had been given in error — a massive overdose that resulted in the child’s death.
Such medication errors are more likely to occur in the ED than in other areas of the hospital for many reasons, says Andrew Sucov, MD, FAEM, medical director of the ED at Rhode Island Hospital in Providence. "Risk factors include extreme time pressure, volume of patients being cared for at a given time, overuse of verbal orders instead of written orders, and multiple staff overlapping on patient care."
Four key areas cause medication errors in EDs, says Robert L. Wears, MD, MS, FACEP: verbal orders, omissions and duplications during resuscitation or other crisis situations, pediatric dose errors, and drugs given to allergic patients. (See prevention story, p. 63.) Wears is a professor in the department of emergency medicine at the University of Florida College of Medicine in Jacksonville.
The staff who make medication mistakes don’t realize they’re making memory or mental calculation errors until it’s too late, says Wears. "It’s like driving to the store on Saturday morning and suddenly finding yourself driving to work. The errors are made at a cognitive level that’s not generally accessible."
Telling staff to be more careful or to double-check everything won’t work, says Wears. "That’s what got us to the place we are," he emphasizes. "What is needed is to carefully restructure the work environment using good error reduction principles such as lack of dependence on memory, simplification, standardization, and lack of dependence on attentiveness."
Individual workers can’t make systematic changes in the process of work, Wears stresses. "Only managers can do that."
Spotlight is on drug errors
Three health care organizations recently issued reports on medication errors, including the Boston-based Institute for Healthcare Improvement, the Washington, DC-based Institute of Medicine, and the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. (For ordering information, see box, p. 63.)
Here are key steps to avoid medication errors, according to ED experts and those reports:
• Identify high-risk medications.
Most medication errors are caused by specific drugs, known as "high-alert" medications, say the Joint Commission and the Institute for Safe Medication Practices in Huntingdon Valley, PA.1 (For details, see ED Management, February 2000, p. 21.) The top five high-alert medications are insulin, opiates and narcotics, injectable potassium chloride (or phosphate) concentrate, intravenous anticoagulants (heparin), and sodium chloride solutions above 0.9%.
The Joint Commission reports that common risk factors leading to errors in administering those drugs include unclear labeling, lack of a check system for medication dosages, and similar drugs kept in close proximity to each other.
• Check system.
Implement a check-back system in which all verbal orders are repeated verbatim, Wears recommends. "This practice caught a verbal order for 1 mg of vecuronium, which was heard as 10 mg of vecuronium," he says.
When a patient with a rapid heart rate needed Verapamil at Rhode Island Hospital’s ED, the wrong drug almost was given. "I inadvertently asked for Valium first, and then Versed. Those are two commonly used medications with similar-sounding names, but absolutely wrong for the situation," Sucov recalls. "Fortunately, I caught the mistake before either was given."
The nurse didn’t question the medications, notes Sucov. "That would have prompted me to think harder for a second and get the correct medication," he says.
• Reduce the number of medications used.
Simplification and standardization are keys to avoiding medication errors, says Wears. "Reduce the formulary to a smaller set of drugs that are very well known," he advises. "Don’t stock drugs which aren’t needed emergently that are known hazards; for example, concentrated potassium chloride."
• Avoid sound-alikes.
Avoid using sound-alike drugs such as Cerebrex and Celebrex, or Norcuron and Narcon, advises Wears. "Also, the spoken words 15 and 50 have been mixed up."
The best way to deal with sound-alike words is to use check-backs, Sucov recommends. "For example, say, That’s five-zero milligrams of X.’ Separating the numbers like this helps."
• Use protocols.
Use standardized written dosing protocols that can be referred to easily, such as standard order sets with premultiplied doses for different ranges, Wears recommends. "These cognitive aids free up mental effort for higher-level tasks," he says.
• Share care plans for patients.
Communicating the care plan for patients is a good error-reduction technique, says Wears. "We avoided a mix-up between an verbal order for Narcan, which the nurse misheard as Norcuron, by clarifying the plan was to wake the patient up, not to intubate," he recalls. Narcan will reverse a narcotic overdose, whereas Norcuron will paralyze patients so they can be intubated and is not used for any other purpose, he explains.
Care plans should be articulated to the team, not just one individual, Wears advises. "In our ED, we noticed that the doctors tended to talk to the doctors and the nurses to the nurses. So we ask people, particularly the team leader, to verbalize their plans."
It sounds simple, but that kind of communication can be awkward, he says. "Sometimes people are unsure and thus hate to speak out loud. But it’s still better to tell your co-workers, for example, I’m not sure whether this is congestive heart failure or chronic obstructive pulmonary disease,’ than to say nothing and let them guess by your actions."
• Use a "call-out" system.
Implement a system where staff use "call-outs" to announce the drug and dose when given, Wears suggests. "This saved us when a 10 kg infant erroneously got 1 mg of Norcuron. That is the standard defasciculating dose for an adult, but a full paralytic dose for this infant."
The nurse called out the dose, and the rest of the team realized it was a paralytic dose and immediately intubated instead of following the usual procedure, Wears explains. "It was caught, but it could have been a disaster."
• Direct orders to a specific individual.
The individual who is to perform specific orders should be preassigned before the situation, he says. "That way, orders aren’t shouted into the air, where everyone can assume someone else will do it, and the patient gets nothing, or two people both do it, and the patient gets a double dose."
• Be an observer in your own ED.
By observing, you might notice that staff rely solely on verbal orders or notes instead of face-to-face communication, which has a better chance of being correct, says Sucov. "Or you might observe that physicians have a tendency to overload orders in certain situations, increasing the likelihood of error," he adds.
• Use charts.
"Drip charts" identify upfront how the drug is mixed, what the concentration ends up being, and how to deliver the proper amount, notes Sucov. "It also prompts you to remind staff of interactions or issues like light sensitivity."
At Rhode Island Hospital’s ED, signs were made to identify the appropriate drugs and dosages for conscious sedation and rapid-sequence induction. They were placed in the rooms where they were likely to be used, says Wears.
"This way, you remind people just when they need it," he says. "We also made pocket cards with the doses so people could have easy access when they wanted it." (See rapid-sequence induction list at left. Also, see charts for conscious sedation dosages and norepinephrine and nitroglycerin infusion rates, enclosed in this issue.)
Reference
1. Cohen MR, Proux SM, Crawford SY, et al. Survey of hospital systems and common serious medication errors. J Health Care Risk Management 1998; 18:16-27.
• Andrew Sucov, MD, Rhode Island Hospital, 593 Eddy St., Davol 141, Providence, RI 02903. Telephone: (401) 444-8388. Fax: (401) 444-4307. E-mail: [email protected].
• Robert L. Wears, MD, MS, FACEP, University of Florida Health Center, Jacksonville, 655 W. Eighth St., Jacksonville, FL 32209. Telephone: (904) 549-4124. Fax: (904) 549-4508. E-mail: [email protected].
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