Sunday, September 03, 2006

Most medication errors are preventable

Medication errors injure 1.5 million people annually, and the extra costs of treatment related to these injuries in hospitals nationwide each year is $3.5 billion.

However, the ultimate cost can be someone's life.

According to the U.S. Food and Drug Administration, 41 percent of all fatal medication errors involve giving an improper dose, 16 percent giving the wrong drug and 16 percent using the wrong route of delivery.

[Click here to read the FDA's web fact-page on medication errors.]

That's why one of the Joint Commission on Accreditation of Health Care Organization's National Patient Safety Goals is to improve the safety of using medications.

[Click here to get JCAHO's Frequently Asked Questions sheet on National Patient Safety Goal #3: "Reduce Medication Errors."]

"It is imperative that all Backus Hospital staff members who have anything to do with medications follow established protocols," said Karen Long, RN, Vice President and Chief Nursing Officer. "The frequency of medication errors nationwide is cause for serious concern, and we need to do our part to eliminate them."

    To comply with JCAHO standards, Backus Hospital has:

  • Removed concentrated electrolytes such as potassium chloride from patient care units.
  • Standardized the number of drug concentrations available in the organization, and ensured that drugs that look or sound alike are limited, identified and stored away from one another.
  • Improved communications between caregivers when ordering medications.
  • Added safety checks prior to dispensing medications.
  • Upgraded electronic medication record-keeping within the hospital, including generating a list of medications that patients take at home, to ensure that drugs administered in the hospital setting don't have a negative interaction. A complete list of medications must be reviewed when a patient enters the hospital, is in the Critical Care Unit or Emergency Department, is moved to an inpatient floor and when they are discharged. The information must include the recommended dose, timing of taking medication and any allergies. The hospital pharmacy prints out a daily list of all medications the patient is on, which is included in the patient's chart for doctors and nurses to review.
  • Built a brand-new pharmacy with a robotic medication dispensing system, which is nearly 100 percent accurate. Now that the robot is in place, the hospital will continue to work towards its goal of electronic ordering of medications, bar coding of medications and patients.

Still, the possibility of human error has not been eradicated, and staff must always be on the alert.

"Anyone who notices a practice that compromises our medication safety procedures is urged to speak up," said Mary Bylone, RN, Assistant Vice President, Patient Care Services and Patient Safety Officer. "Attention to detail, and speaking out as soon as a problem is noticed, can make the difference between life and death."

Peter Shea, MD, Medical Director, said staff must maintain its focus on medication-related patient safety measures, because the use of different medications has increased significantly and patients must maintain their medications as they move through the healthcare system.

"Day in and day out, it is imperative that we keep the 'five rights' in mind," Dr. Shea said. "Right medication, right dose, right patient, right route of delivery, right time. It sounds simple, but you'd be surprised how many preventable injuries occur because clinicians don't follow these guidelines."

Anyone with questions about the National Patient Safety Goals, or suggestions to help Backus improve patient safety, can call Ms. Bylone at 860-889-8331 ext. 2771, or Joe Hughes, Director of Quality Improvement, at 860-889-8331 ext. 2345.

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