Uh oh, did “I” do

that ?
Medication Errors in
Long-Term Care

John F. Mitchell, Pharm.D., FASHP

Medication Safety Consultant
Recipient, ISMP CHEERS Award
formerly
Medication Safety Coordinator
University of Michigan Hospitals
 Our goals for today

• Define medication errors and classify their

significance
• Understand the extent of medication errors
and their impact on patient care
• Discuss the many factors that contribute to
errors and the impulse to “place blame” on
healthcare workers
• Examine approaches to minimize the risk of
medication errors with applications to LTC
 To Err Is Human

Kohn LT,
Corrigan JM,
Donaldson MS,
Eds. To Err Is
Human.
Washington
National Press,
Wash, DC. 2000.
 Defining medication errors

"A medication error is any preventable event that

may cause or lead to inappropriate medication
use or patient harm while the medication is in the
control of the health care professional, patient, or
consumer. Such events may be related to:
• professional practice • dispensing
• health care products • distribution
• procedures and systems • administration
• product labeling, packaging, • education
and nomenclature • monitoring
National Coordinating Committee-Medication Error Reporting and Prevention (NCC MERP); accessed at
http://www.nccmerp.org/aboutMedErrors.html; Jan. 2012.
If you saw this, would you fly ?

Extra Extra
Airlines expect 1-2
jets to crash daily
Over 1000 deaths expected weekly
 Buy what about being a patient in
the health care system

Extra Extra 44,000 – 98,000

Airlines expect 1-2 jets to
crash daily
= deaths annually
due to
medical errors
Over 1000 deaths expected
weekly

Kohn et al. Committee on quality health care in America. IOM. Academy Press. 1999.
 How medical errors rank as
cause of mortality

Heart Accidents
616,067 123,706

Cancer Medical
562,875 Errors
~100,000
Stroke Alzheimer's
135,952 74,632

Lung Diabetes
127,924 71,382
www.cdc.gov/nchs/fastats. Accessed Jan 2012. Based on 2007 data.
 Some reasons errors occur

• verbal orders
• poor communications within healthcare team
• poor handwriting
• improper drug selection
• missing medication
• incorrect scheduling
• polypharmacy
• drug interactions
• availability of floor stock (no second check)
• look alike / sound alike drugs
• hectic work environment
• lack of computer decision support
 Classifying medication errors

A circumstances exist for potential errors to occur

B an error occurred but did not reach the patient
C error reached the patient but did not cause harm
D patient monitoring required to determine lack of harm
E error caused temporary harm and some intervention
F temporary harm with initial or prolonged hospitalization
G error resulted in permanent patient harm
H error required intervention to sustain the patient’s life
I error contributed to the patient’s death

NCC MERP. accessed Jan 2012. www.nccmerp.org

A true comedy (tragedy) of errors
 A true comedy of errors

• Attending MD tells the resident to give the patient

“free water” (meaning let her drink water”)
• Resident assumes he meant an IV and writes for
water to be given IV
• New RN can’t find IV water and calls pharmacy
asking where they get IVs; pharmacy asks no
questions and tells the RN they get them from C.S.
• RN obtains IV from C.S. never questioning RN
why she by-passed pharmacy; water bag says
“water for irrigation”
(continued)
 A true comedy of errors

• RN attaches the bag to regular IV tubing;

RN infuses 600 mL of “free water”
• At change of shift, more experienced RN notes
patient is lethargic, sees bag of water, removes
it, and calls MD

Free water has no electrolytes and would

likely have caused burst red blood cells and
death if the second RN hadn’t interceded
 What did staff do wrong ?
Should someone be fired ?

• MD #1: used an unfamiliar term “free water”

when he meant let the patient drink water
• MD #2: intimidated to clarify so he wrote what
he assumed was supposed to be an IV
• RN: well-meaning, wanted to help her patient;
she called pharmacy and talked to whoever
answered the phone; went to obtain the IV
directly from Central Stores Dept

(continued)
 What did staff do wrong ?
Should someone be fired ?

• Pharmacy tech: didn’t identify herself as a

tech; didn’t ask why the RN had this unusual
request; didn’t consider having pharmacist
consult with RN
• C.S. staff: never questioned RN why
pharmacy was not involved; provided drug
directly to RN without normal pharmacy
process
Treating employees with a
Just Culture approach
 Managing Errors

JUST CULTURE
• Concept
You are a fallible human being,
susceptible to human error and behavior
drift
• Human error
• At-risk behavior
• Reckless behavior
 “Just Culture”
Human error

Inadvertently doing other

than what should have
been done; a slip, lapse,
or mistake.

Manage through
• Choices
• Procedures
• Training Console
• Design
• Environment
“Creating an Environment of Safety: Just Culture in the Workplace”. ASHP. Nov 4, 2007.
 “Just Culture”
At-risk behavior
A behavioral choice that increases
risk where risk is not recognized,
or is mistakenly believed to be
justified.

Manage through:
• Removing incentives for
at-risk behaviors
• Creating incentives for
healthy behaviors Coach
• Increasing situational
awareness
“Creating an Environment of Safety: Just Culture in the Workplace”. ASHP. Nov 4, 2007.
 “Just Culture”
Reckless behavior

A behavioral choice to
consciously disregard
a substantial and
unjustifiable risk.

Manage through:
• Remedial action
Punish
• Punitive action

“Creating an Environment of Safety: Just Culture in the Workplace”. ASHP. Nov 4, 2007.
Treating the employee (second victim)
 Dealing with the SECOND VICTIM
in a “Just Culture” environment

• Kimberly H, age 50, an RN with 27 years of

pediatric experience
• She made a mathematical error that led to an
overdose of calcium chloride and the subsequent
death of a critically ill infant
• She was fired; her licensing board made her pay a
fine and placed her on 4 years probation
• Despite receiving a perfect score in an advanced
cardiac life support certification exam, she was
refused work and could not find a job
http://seattletimes.nwsource.com/html/localnews/2014830569_nurse21m.html
 Dealing with the SECOND VICTIM
in a “Just Culture” environment

• With no job offers, she experienced increasing

isolation, despair, regret, hopelessness, low self-
esteem, and shame and guilt regarding her role in the
fatal error

Kimberly took her own life

7 months after the death of
her patient

http://seattletimes.nwsource.com/html/localnews/2014830569_nurse21m.html
 Dealing with the SECOND VICTIM
in a “Just Culture” environment

Five rights of the second victim

TRUST:
• Treatment that is just
• Respect
• Understanding and compassion
• Supportive care
• Transparency and opportunity to contribute

Denham C. TRUST: the 5 rights of the second victim. J Patient Saf. 2007;3(2):107-119.
Focusing in on long-term care
 Med errors in nursing homes
• 12-month observational study
• 18 participating nursing homes
• 28,839 nursing home resident-months

• 546 drug events (1.89 per 100 resident-months)

– 1 fatality
– 31 (6%) were life-threatening
– 206 (38%) were serious
– antipsychotics, antidepressants, sedatives/hypnotics
and anticoagulants were most common
Incidence and preventability of adverse drug events in nursing homes. Gurwitz JH. Am J
Med. 10:87-94. August 2000.
 Nursing home non-physician errors

• In 2005, a Gurwitz study1 estimated

800,000 medication errors yearly in LTC
facilities.
• Barker2 reported average error rates in
nursing homes / SNFs = 12.2%
– non-prescribed drug = 44.8%
– wrong dose = 11%
– wrong route = 2%
– wrong dosage form = 0.4%
1. Gurwitz JH et al. American Journal of Medicine. 118(3):251–258. 2005 2. Barker KN et al. American
Journal of Hospital Pharmacy. 39:987–991. 1982.
 Prescription errors of omission
in nursing homes

Patient Type Drug Omission

65+ with CHF 62% no ACEI1
65+ with MI 60% no aspirin1
65+ with MI 74% no beta-blocker1
65+ with stroke 37% no anticoag or ASA1
65+ with osteoporosis 51% no treatment1
patients with depression 45% no treatment2
patients with pain 20-55% uncontrolled3

1. Sloane PD et al. Archives of Internal Medicine.164(18):2031–2037. 2. Brown MN et al. Journal of the American Geriatrics
Society. 50:69–76. 3. American Geriatrics Society. Journal of the American Geriatrics Society. 50(Suppl. 6):S205–S224.
OK – so what can we do ?
 Reducing medication errors in
long-term care facilities

• In general:
– a safety culture is pivotal to improving
medication safety (encourage voluntary
reporting)
– senior management must devote adequate
attention to safety
– provide sufficient resources to quality
improvement and safety teams
– authorize resources to invest in technologies,
such as computerized provider order entry
(CPOE) and electronic health records
Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html.
 Reducing medication errors in
long-term care facilities

• Prescribers:
– use sound med reconciliation techniques
– avoid verbal orders except in emergencies
– avoid abbreviations (U for units seen as a 0)
– inform patients of reasons for all medications
– work as a team with consultant pharmacists
and nurses
– use special caution with high-risk medications
– report errors and ADEs

Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html.

 Reducing medication errors in
long-term care facilities

• Pharmacists:
– monitor the medication safety literature
– in conjunction with doctors and nurses,
develop, implement, and follow a medication
error avoidance plan
– verify the accurate entry of data on new
prescriptions (avoid abbreviations; use
TALLman lettering)
e.g. Morphine HYDROmorphone
– report errors and near misses to internal and
external medication error reporting programs
Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html.
 Reducing medication errors in
long-term care facilities

• Nurses:
– foster a commitment to patients’ rights
(YOU are the patient’s advocate)
– be prepared and confident in questioning
medication orders
– participate in, or lead, evaluations of the
efficacy of new safety systems and
technology
– support a culture that values accurate
reporting of medication errors
Preventing Medication Errors: Quality Chasm Series. accessed 2010. www.nap.edu/catalog/11623.html.
Questions