b'LEADERSHIP GUIDE|evaluating healthcare organizations andtechniques. medication label prior to dispens-inspiring them to excel in providing safePatient misuse because of poor under- ing, administering, or restocking and effective care that is of the highest qual- standing of directions for medicationmedications.ity and value. Its vision is that all peopleuse. Storing medications with look-alike, always experience the safest, highest quality,Considerable research has been donesound-alike labels and packaging.best-value healthcare across settings (Theon behaviors associated with medication5. Drug stock, storage, distribution: Joint Commission, 2018a). errors. The National Coordinating CouncilLeaving medications in an unlocked for Medication Error and Reporting (NCCarea.TYPES OF MEDICATION ERRORS THATMERP) (2014) has identified some of thesePreparing IV admixtures outside of INVOLVE HEALTHCARE PROFESSIONALS behaviors and categorized them into 12the pharmacy.It is an especially hectic day on a full-to-ca- groups. A summary of the information6. Environment/staffing patterns:pacity post-surgical unit. Monica is workingprovided for these groups follows. For aDealing with multiple priori-a double shift because one of her colleaguesdetailed description of at-risk behaviors,ties while performing complex called in sick. Monica is tired and just wantsaccess https://www.nccmerp.org/reduc- procedures.to go home. She is in a hurry to administering-medication errors-associated-risk-be- Holding or admitting overflow the last medication of her shift. She entershaviors-healthcare-professionals. patients in inappropriate settings.the room where two of her patients are recov- 1. Patient information: Failure to adequately supervise staff.ering from surgery. Their names are DanielleFailure to identify patients by usingFailure to adequately orient staff.Moran and Danielle Morris. Monica knowstwo identifiers. Inadequate staffing based on patient both of the patients and does not use theFailure to check for patient allergiesacuity.usual multiple methods of patient identi- before prescribing, dispensing, or7.Patient education:fication. Mrs. Moran is supposed to receiveadministering medications. Failure to educate patients when pre-a prescribed antibiotic orally. Monica acci- Failure to check the patients com- scribing, administering, or dispens-dentally gives the antibiotic to Mrs. Morris.plete medication profile. ing medications.When Mrs. Morris asks what the medica- 2. Drug information: Disregarding concerns of patients tion is, Monica explains that it is tetracy- Prescribing, dispensing, or adminis- or caregivers about a medications cline. Mrs. Morris gasps and exclaims, Buttering medications without adequateappearance, reactions, side effects, Im deathly allergic to tetracycline! A seri- knowledge of the medications. or other expressed worry.ous medication error has been made. TheUnnecessary use of manualFailure to follow up concerning the patient has received medication that she iscalculations. desired effects of medication com-allergic to. Failure to question unusually largepared to the patients observed or Medication errors are the most com- doses of medication ordered. reported effects.mon medical errors. Data from the FDAFailure to inspect the medication8. Staff education:indicate that the most common errorprior to administration. Inadequate orientation of new staff involving medication was administeringFailure to perform medicationor of agency staff.an improper dose. Giving the wrong dosereconciliation. No organizational incentives to accounts for about 41% of fatal medication3. Communication: achieve certification.errors. Administering the wrong medica- Rushed, inadequate communicationNo organizational incentives tion and using the wrong route of adminis- with colleagues. to attend continuing education tration each accounted for 16% of the errorsFailure to speak up or feeling intim- activities.(Stoppler, 2018). idated when there is a questionLack of a structured and ongoing Regarding medication errors that involveor concern about the prescribedstaff competency program that is healthcare professionals, the FDA notes thatmedication. related to medication use.medication errors can occur at any pointUse of error-prone abbreviations or9. Quality/culture:in the distribution process including (FDA,dangerous designations. Sacrificing safety for timeliness.2017): Unnecessary use of verbal orders. Failure to report errors.The FDA also identifies common causesNot confirming verbal orders. Failure to share error information.of medication errors, including (FDA, 2017)4. Labeling, packaging, nomenclature: Organizational culture of secrecy Poor communication. Absent or poor labeling of med- instead of openness about medica-Ambiguities in product names, direc- ications or equipment needed totion errors.tions for use, medical abbreviations. administer the medications. Organizational culture of fin-Poor writing; poor procedures orFailure to completely read theger-pointing (blaming someone) 14 LEADERSHIP GUIDE|2020| www.elitecme.com'