The medication errors experienced by actor Dennis Quaid's newborn twins have received a lot of media attention. While hospitalized at Cedars-Sinai Medical Center in Los Angeles last November for treatment of a staph infection, Quaid's twins received a dangerous overdose of heparin. Each baby received 10,000 units of the drug rather than the 10 units they were supposed to receive. Quaid and his wife Kimberly Buffington have sued the maker of the heparin formulation the children received, and are in the process of setting up a foundation to address the problem of hospital errors. Although this experience aimed the spotlight at mistakes made in the hospital setting, medication errors are all too prevalent in long-term care as well.
A drug safety study completed by the Institute of Medicine (IOM) found that medication errors are surprisingly common; approxi- mately 800,000 preventable adverse drug events (ADE) occur each year in long-term care facilities and $887 million is spent annually to treat medication errors that occur in Medicare recipients ages 65 and older.1 A 2005 study published in the American Journal of Medicine, indicated that one out of every 10 nursing home residents suffers a medication-related injury and that 73 percent of the most severe injuries, including internal bleeding and death, was preventable.2
Lawsuits involving drug errors made by nurses are also on the rise. In these cases, the court determines liability based on the standard of care required of nurses when administering drugs. In many instances, if the nurse had known more about the proper dose, administration route, or procedure connected with giving the drug, the mistake that resulted in the lawsuit might have been avoided.3 Because most medication errors occur in the ordering stage, primarily prescription of the wrong dose and failure to recognize drug interactions, it is imperative that the nurse be knowledgeable about the medications that are being administered.1 Because of the serious consequences resulting from medication errors, implementation of effective risk management should be the focus of every facility's quality assessment and assurance program. All processes related to medication administration should be evaluated for safety and prioritized for quality improvement as the need arises. As described by the IOM, designing healthcare processes for safety involves a three-part strategy: (1) designing systems to prevent errors, (2) designing procedures to make errors visible when they do occur, and (3) designing procedures that can mitigate the harm to residents from errors that are not detected or intercepted.4
Designing systems to prevent errors
Preventing errors begins with receipt and review of physician's orders. The American Hospital Association reports that common types of medication errors include the prescription of medication based on incomplete patient information such as not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results. Another common type of error is the result of miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations. The nurses responsible for the review and transcription of a physician's orders must be thorough, reliable, and diligent in analysis and clarification. Having knowledge of a medication's safe dosage limits, potential side effects, toxicity, and indications and contraindications for use are important to the task. Illegible, unclear, or confusing medication orders must be clarified and the physician must be notified when communication is questionable or a discrepancy is identified. The organization's standard abbreviation list should be used consistently by all nurses. If such a list is not available, physician orders should be written out in full to avoid miscommunication. For guidance in establishing a standard abbreviation list, the Joint Commission has issued a “Do Not Use” list of abbreviations that are commonly misinterpreted. (http://www.jointcommission.org/PatientSafety/DoNotUseList/)
The process for administration must also be designed to prevent errors. One approach to safe medication administration is the use of the “six rights”:
the right drug
to the right resident
at the right time
the right dose
by the right route, and
with the right documentation
These principles should be included in the orientation of newly employed nurses and reviewed on a regular basis thereafter. The use of consistent staffing assignments whereby the same nurses are responsible for administering medications to the same residents on a daily basis, can promote a greater understanding of each resident's medication regimen and increase staff awareness of resident response to treatment. All nursing staff should be aware of dangerous drug interactions.