A medication error investigation should never dissolve into a blame game. Because nurses tend to be at the end of the care chain, do they get an unfair share of attention when errors happen?

Chain Reaction

They do, stated Lauren Denney, RN, medication safety specialist with the Institute for Safe Medication Practices (ISMP) in Philadelphia.

"Because the nurse is at the final stage of the error process, that is where all the focus ends up being," she said. "So many times we hear that if the nurse had only followed the five rights of medication administration then an error would never have occurred. That's not true when you really look at the process of how errors occur."

According to Susan Paparella, MSN, RN, vice president of ISMP, the error process often begins long before a patient is administered an incorrect medication. It's a chain reaction that involves everyone connected with prescribing, dispensing and administering medication or care to the patient, from physicians and pharmacists to nurses and everyone in between.

By the Numbers

Unfortunately, because hospitals tend to see medication errors as isolated incidents with a singular "guilty" party, internal error rate data may paint an inaccurate picture of risk factors. It's a trend Paparella would like to see changed.

"While most organizations report an error rate, what they really have is an error reporting rate," Paparella stated.  "Using this as a measure is not a bad thing because it tells you about your organization's culture and expectations around reporting and transparency for safety. The fallacy is when organizations believe that this error reporting rate represents what actually is going on with medication safety- creating a real false sense of security.

Paparella would prefer hospitals refer to such numbers as the "capture rate" of error instead of using a literal translation.

Zero Sum Game

In any case, is it possible to reduce error rates to zero?

"I think we can strive to get very close," Denney insisted. "For nursing, that means modifying certain risky behaviors that have existed in practice for a long time. A lot of those practices fall under the way-we've-always-done-things thought process."

Denney detailed how some of the most serious errors can be eliminated with simpler solutions. She explained how nurses have measured an oral medication in a parenteral syringe, because "that's what's available." Various distractions have resulted in oral medications being administered intravenously to patients.

"This is such a preventable error," Denney said. "So many nurses were never made aware of devices with fail-safe features or they weren't made available to them. If they really knew the potential for this kind of risk, we could begin the process of eliminating it."

Double Edge

Technology has played a significant role in medication safety in recent years. For example, automated medication dispensing and wristband scanning have played an important role in assisting hospitals to reduce errors.

"Technology is definitely an important piece of the puzzle," said Paparella, who acknowledging technology can be a double-edged sword. "Younger nurses who have grown up with technology seem to be better at integrating it into their daily practice. The challenge there is making sure these nurses understand that technology is a tool and does not replace our critical thinking."

The Big Picture

The most effective approach to medication error prevention integrates common protocols across the entire healthcare spectrum within a "just culture" framework.

ISMP offers a Practitioner in Residence Program to help hospitals design such a plan. The week-long program includes sessions in risk identification, medication analysis, failure mode and effect analysis, root cause analysis and data management.

For Paparella, a big picture approach is best when addressing a problem as big as medication errors. "There's never just one cause," she stressed. "This isn't a nursing problem; it's a multidisciplinary problem. With the right comprehensive approach, we can significantly reduce errors and their potential risk together."

Luke Cowles is senior regional editor at ADVANCE.