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Risk Management » Practice Tips
July 2009
Medication Safety in Long Term Care
Medication errors and adverse drug events are the most common errors in healthcare. Minimum Data Set (MDS) review data indicates that, on average nationally, 58.6% of residents receive nine or more different medications. As the number of medications administered increases so does the potential for errors and adverse events.
A medication error is defined by The Centers for Medicare and Medicaid Services (CMS) as “preparation or administration of medications or biologicals that is not in accordance with the prescriber’s order, manufacturer specifications, and accepted professional standards.” A significant medication error is one that “causes the resident discomfort or jeopardizes the resident’s health and safety.”
An adverse drug event is an injury resulting from the use of medication. It may be preventable (such as a medication error) or nonpreventable (such as a side effect or previously unknown allergy).
In a series of studies focused on medication administration in the long term care setting, Gurwitz and his peers determined that as many as 51% of adverse drug events in long term care facilities were preventable. Reducing preventable errors is a huge opportunity to improve resident safety.
Culture of Safety
Medication errors are usually the result of system failures rather than a single individual’s mistake. Medication administration is complex and involves many processes and individuals. It is important to use a systems approach to improving medication safety. Establishing safety as an organizational value is a crucial first step.
Key points for Leadership include:
- Create a blame free environment that does not penalize staff for making mistakes.
- Make resident safety a strategic goal and educate your governing board about medication error reduction.
- Support and encourage error reporting. Understand that this will result in increased numbers resulting in data that is necessary and useful.
- Be involved in creating the culture. Find out what resources are needed to make improvements and support the change.
Identifying Errors
Every facility should have mechanisms in place to identify actual and potential medication errors.
Key points include:
- Use medication error reports to collect information about the types and severity of errors that occur.
- Choose a tool that captures actual errors, near misses and prevented (or caught) errors.
- Track and trend errors to target improvement activities.
- Establish a multidisciplinary medication safety team to review reports, investigate the system, recommend and implement change.
- Medication errors are under reported and other mechanisms such as record reviews and direct observation of medication administration are also good sources of information.
Staff Competency/Human Factors
Good systems have good people. Assess all new staff for medication competencies and provide targeted education as needed during orientation. Provide ongoing education specific to medication administration and safety, error reporting and facility policies and practices to current staff. Target education to staff and facility needs, at a level appropriate to the learner.
Human factor analysis is the study of how we interact with the environment and how it affects performance. Researchers have begun to study medications errors using human factor analysis.
Lessons learned include:
- Provide well lit medication preparation areas located away from noise and distractions.
- Make current reference material easily accessible.
- Ensure access to a pharmacist.
- Use unit doses for medications.
- Encourage staff to verify questionable orders.
- Administer medications using the 6 rights of medication safety: Right Medication, Route, Time, Resident, Dosage, Documentation.
Teamwork
Improving medication safety requires a team approach. Your team should include staff who administer the medications, as well as staff who provide resident care, a clinical pharmacist, your risk manager, a physician and a dietician. Some facilities include residents on their team. In addition to reviewing error reports, the team should conduct risk assessments, develop medication policies and tools and ensure this information is well communicated.
Policies and Procedures
Policies and procedures should be living documents that provide a resource for staff and foster the organization’s commitment to resident safety. In addition to standard medication administration policies, consider the following:
- High Alert Medications. Insulin, anticoagulants and psychoactive drugs are examples of medications with the potential for serious harm that require additional precautions. Your policy should include a list of medications, identify what additional precautions are necessary and any expected resident monitoring.
- Verbal and Telephone orders. Limit use of verbal or telephone orders to emergencies. Define and require a process for order verification (such as read back confirmed) and how to document.
- Unacceptable Abbreviations. Define and publish a list of unacceptable abbreviations. Audit records and hold staff accountable.
- Medication Reconciliation. Resident transfers are a significant source for medication errors. Develop a policy that outlines a process for reconciling medications when a resident is admitted, transferred or readmitted and for providing a current medication list at discharge.
- Medication Renewals. Clearly define the process for medication renewals/edits.
Additional Resources
A Systems Approach to Quality Improvement in Long Term Care: Safe Medication Practices Workbook.
www.mass.gov/Eeohhs2/docs/dph/patient_safety/safe_med_practices_08.pdf
ISMP (Institute for Safe Medication Practice)
Do Not Crush list
www.ismp.org/Tools/DoNotCrush.pdf
Error Prone Abbreviations list
www.ismp.org/Tools/errorproneabbreviations.pdf
Confused Drug Names list
www.ismp.org/Tools/confuseddrugnames.pdf
REFERENCES
Risk Analysis: Medication Safety, Continuing Care Risk Management. ECRI, November 2007.
Institute of Medicine. Preventing Medication Errors. National Academy Press, 2007.
Gurwitz, JH, Field TS, Arvon J et al. Incidence and preventability of of adverse drug events in nursing homes. Am J Med 2009; 109 (2): 87-94.
Gurwitz, JH, Field TS, Judge J et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med 2005; 188(3): 251-8.
Medical Mutual's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.