This offering expires in 2 years: February 6, 2008
The goal of this continuing education offering is to provide nurses with current information on medication safety issues. After reading this article, you will be able to:
1. Define a medication error.
2. Describe the medication use process as a complex system.
3. Differentiate between active and latent error.
4. List high-leverage strategies for use with high-alert medications, high-risk populations and error-prone processes.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
A 70-year-old male patient presents in the ED following a horseback riding accident, where he and his horse fell down a steep hill. Fortunately, the patient's chest X-ray showed only a possible small sternal fracture. Although the physician recommended the patient stay for observation and pain management, the patient declined and asked to be discharged. Pain management was discussed and morphine 10 mg IM was ordered for immediate use, with a discharge prescription for oral meperidine (Demerol).
During the selection of the drug, the nurse was distracted by another patient and temporarily placed the drug vial in her pocket. After assisting the other patient, the nurse removed the drug vial from her pocket, and administered the pain medication intramuscularly. The patient was discharged about 20 minutes later, alert and in stable condition.
Only later, during the change-of-shift narcotic count, was it discovered a substitution error had been made. Hydromorphone (Dilaudid) 10 mg had been inadvertently administered instead of the prescribed morphine 10 mg. Simultaneous to this discovery, while the patient was traveling home with his family, he suffered a respiratory arrest. Tragically, resuscitation attempts failed.
Medication errors have always existed, but only recently have these errors been acknowledged as a significant problem. Like countless other medication errors that occur each year, this story of a lethal yet preventable adverse drug event was not the result of a careless individual. Rather, it was the result of a series of complex, risk-laden system elements, which, until that day, had remained relatively unrecognized in the organization.
According to the Institute of Medicine, 44,000-98,000 patients die annually due to preventable healthcare errors. Medication errors, a subset of medical errors, account for more than 7,000 deaths annually, more than those associated with workplace injuries. Studies also have shown medication errors account for one out of every 131 outpatient deaths, and one out of every 854 deaths per year in the inpatient setting.1
Regardless of the practice setting, the medication use process is complex, involving many steps and multiple practitioners. Medication error can occur at any point, with close to a third of all medication errors occurring during the administration phase. By the very nature of the process, nurses remain one of the last lines of defense.
What Is a Medication Error?
The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the practitioner or patient." The term "preventable" clearly indicates strategies exist to stop these events from occurring.
"Error" has been defined by James Reason as "the failure of a planned action to be completed as intended such as an error of execution or the use of a wrong plan to achieve an aim (i.e., error of planning)."1 According to Reason, errors can be divided into distinct types. At the "blunt end" are latent errors, which happen as a result of delayed-reaction consequences of administrative decisions, such as the failure to adopt advance technologies to prevent error. Active failures, on the other hand, refer to errors made directly by practitioners at the "sharp end," or at the point of care.
The effects of active failures are felt almost immediately. Latent failures are more of a challenge to fix. They often lie dormant in organizations for long periods of time without being problematic. Latent failures are nearly invisible, yet given the right set of circumstances, the failures in the system become apparent when least expected, setting the stage for an adverse drug event.
To illustrate the interaction of active and latent failures, consider the case study above. The active failure, or most proximal cause of the error, was the inadvertent selection and administration of hydromorphone instead of morphine. The latent failures included the expedited discharge of a patient without appropriate monitoring, likely due to the diversion status of the ED and the lack of policies regarding safe discharge parameters following narcotic administration.
The unusual and unexpected storage of concentrated hydromorphone in the ED, the look-alike packaging of both products, the knowledge that the names "morphine" and "hydromorphone" are commonly confused by nurses, the abbreviation of the drug name on the order as "morph," and the lack of staff were all contributing latent factors leading to this tragedy.
Healthcare organizations and practitioners need to step back and focus their investigation on the critical role latent failures play in errors. Ensuring safe medication use requires an eye for hazard prevention and a proactive approach to recognize and correct failures in the system before harm can occur.