Medication errors are a constant source of concern in both retail and institutional settings, making medication errors the leading cause of preventable patient harm in the U.S. healthcare system. A recent review indicated that 1.6% of prescriptions dispensed are associated with errors.
If 16 of every 1,000 scripts dispensed are associated with errors, maybe we should do something. Sounds fairly straightforward, but it may not be as simple as it sounds.
Organizations often have difficulty responding to major improvement initiatives because many of your employees suspect this is a one-time thing and soon it will be business as usual until something else becomes a priority.
Here are five tips to get going and avoid the traps that come with implementing new procedures.
To make an effort to begin to reduce the incidence of medication errors, you need to know your current error level. First, define what an error is. Some pharmacy managers count only those errors that aren’t caught before the medication is delivered to the patient, while others are stricter. Certain organizations include appropriate and correct prescriptions that were placed in the wrong tote in the correct facility as an error.
Answering the question, “What is an error?” is worth the time it takes to come to an understanding of what it is we’re trying to fix. Look at all the relevant data you have and see what you already collected that helps you describe an error. It makes little sense to set a goal of limiting or eliminating medication errors if you don’t have the means to determine when that event takes place. It may make sense to first determine how you can identify the errors you want to eliminate.
OK. You have identified the target, which is reducing medication errors by a certain percentage or focusing on eliminating errors that result in patient harm. Next comes the hard part. Employees have been trained to believe that initiatives that come from the top don’t last long. Once the initial enthusiasm runs its course, it’s back to business as usual.
Before you pitch your staff on the importance of this effort, demonstrate that this is going to stick. Let everyone know that performance reviews will include an element related to reducing medication errors.
Keep a running score of how many medication errors have been discovered each month. Imagine a prominently placed tracking score of how many consecutive days have passed since a medication error has been experienced. As the numbers grow, your staff will want to keep the record going. No one wants to start over after having achieved 100 days of no errors.
When you roll out the “no errors” campaign, make sure everyone knows what you’re trying to achieve and why. Identify the people in your group that act as influencers and sell them on the importance of reducing errors. They will help maintain the momentum.
Whenever an airplane crashes in the U.S., the National Transportation Safety Board initiates an investigation. The investigators go to extraordinary lengths to uncover the cause, even if it means recovering and reassembling the airplane to determine which structures failed. They reconstruct the flight and examine the flight data recorder and cockpit voice recorder to uncover what the pilots experienced and how they reacted. These investigations can take years to complete, but the results will uncover human errors as well as equipment failures and can save thousands of lives based on what is learned.
When you complete your own investigation, make sure you disseminate the conclusions widely and point out how the results should change behavior to keep these errors from happening again. This demonstrates commitment to reducing and eliminating errors and will get your team refocused on the mission. Breaking a “no errors” streak will be disappointing, so focus on starting a new streak based on what you’ve learned.
Your pharmacy software has tools that can aid in tracking errors and providing insights into recurring issues. Reporting what went wrong, explaining how the error could have been prevented, and asking your crew to help make sure it isn’t repeated will help make the most of the experience. Of course, we must avoid assigning blame, but concentrate on learning how to do better. If the program isn't working, your team will be disappointed, you want them to want this to succeed, so focus on the good things that will happen if we learn the lessons that will improve our performance.
Few things in our work lives bring as much joy as the experience of tackling a problem and seeing success. Watching your error-free days approach 100, 300, or even 500; Hearing customer testimonials about the impact of your work to eliminate errors; or learning that your pharmacy has become a leader in the industry by focusing on banishing medication errors.
So, celebrate these events. Nothing succeeds like success.
Medication errors can have devastating impacts on the patients we serve. Utilizing advanced tools, such as your pharmacy software can aid in tracking errors, reporting and providing insights into recurring issues. If we don’t settle for “good enough”, your pharmacy staff will rise to the challenge and everyone wins.
