When I read the following article, I sat and thought to myself, “How obvious!” It amazes me that we never take the time to step back and observe the entire process that we go through daily in taking care of our patients.
I can tell you that in my current practice, I am bombarded constantly for prn medications, and my patients are all up and out of bed, so they can come and find you. There are days when I literally have full sheets of prn MARs for each patient and I usually have a patient load of 8 or 9.
Passing meds is the most critical time for a nurse. There are so many factors to take into account. We have to not only check our own processes, but we also have to recheck the last shift’s administration processes to ensure safe administration.
I was shocked to see how much medication errors cost each year, but I am mortified to know that each error involved a real, live person.
Please read this article and let me know what you think.
Victoria Colliver, Chronicle Staff Writer
Wednesday, October 28, 2009
For nurses, constant interruptions while tending to a patient are part of the job. But a distraction that happens while they’re giving medications could have deadly results.
UCSF program to improve accuracy in administering drugs – with particular emphasis on reducing interruptions that often lead to mistakes – resulted in a nearly 88 percent drop in errors over 36 months at the nine Bay Area hospitals, according to results being released today.
“Medication errors make up the largest slice of the medical error pie,” said Julie Kliger, director of UCSF’s Integrated Nurse Leadership Program, which developed the medication errors program. “Improving these numbers is a huge benefit to patient safety and, secondarily, it reduces costs.
“Errors in administering medication cause about 400,000 preventable injuries in hospitals and about $3.5 billion in extra medical costs a year, according to the Institute of Medicine.
The UCSF program, which was funded by the Gordon and Betty Moore Foundation, involved UCSF Medical Center, Kaiser hospitals in Hayward and Fremont, San Francisco General Hospital, St. Rose Hospital in Hayward, Contra Costa County Medical Center, Stanford Hospital in Palo Alto, San Mateo Medical Center and Sequoia Hospital in Redwood City.
Striving to reduce interruptions that lead to mistakes, teams of nurses at the different hospitals came up with a variety of methods – often surprisingly low tech – to alert others they were administering medications. The strategies included everything from wearing brightly colored vests or sashes to establishing “quiet zones” or making announcements at key points in the day when medications are being administered.
At San Francisco General, for example, nurses found they were constantly being interrupted in the medication room because their colleagues could see them through the windows. So they covered the windows.
The solutions “have to be low tech because we, as staff nurses, don’t have the money or ability to make high-tech changes,” said Celeste Arbis, a registered nurse in the medical-surgical unit there. “Something as simple as changing the process just a little bit can make a big difference.
“Some hospitals, such as Kaiser, have high-tech methods to reduce medication errors. Kaiser hospitals use bar-coded patient identification bands, which allow nurses to scan the bar code on the medication against the patient’s wristband to make sure they match.
Such advances may reduce mistakes by decreasing the risk of giving the wrong medicines, but they don’t stop interruptions or eliminate all mistakes, said Joanne Mette, chief nursing officer at Kaiser Permanente in Hayward and Fremont.
Mette said nurses can be interrupted five to 10 times in the course of giving one medication. Kaiser nurses opted to use fluorescent sashes to signal they were in the middle of giving a patient medications and conducting necessary safety checks.
“We wear the sash because you can get interrupted doing the bar coding,” Mette said, adding that a medication error isn’t limited to giving the wrong medication, but includes even a minor delay in delivery. “We liken it to flying a 747. They never give up their safety checks and we don’t give up ours.
“The flight comparison is particularly apt, given that the program borrowed its techniques from the airline industry. The Federal Aviation Administration established the “sterile cockpit” rule, which means pilots must refrain from all nonessential activities during critical phases of the flight, typically under 10,000 feet.
“Distraction for them is anything under 10,000 feet,” said Kliger, of the nurse leadership program. “In the nurses’ world, it’s when giving medications.
“Aside from reducing interruptions, the program established other safety techniques, including requiring nurses to check two forms of patient identification before giving medications, explaining the drug to the patient and keeping it in the package until they’re at the bedside.
Nurses attributed much of the program’s success to allowing those on the front lines to develop and tailor their own solutions. What worked in one hospital sometimes didn’t work in another. Success also varied from unit to unit within each hospital.
At St. Rose Hospital in Hayward, for example, nurses in the maternity wards found the sashes too flimsy and opted instead to use bright green vests. In the large medical-surgical units, nurses rejected the vests and sashes in favor of carrying yellow folders. In the hospital’s intensive care unit, nurses put a border on the floor around the electronic medication dispensing machine along with an overhead sign.
Linda Aug, nursing supervisor in the medical-surgical unit, said St. Rose nurses were a bit apprehensive at first because they didn’t realize they were distracted or making mistakes. But the techniques reduced the hospital’s interruption rate from 53 percent of the time in 2006 to 32 percent in 2007 and 2008. The rate for the first nine months of this year has been just 12 percent. The program did not reveal individual hospital error rates.
“It’s been a whole hospital-wide awakening,” she said. “We learned that it wasn’t something to be afraid or threatened by. It’s for the patient.
A 36-month program involving nine Bay Area hospitals found:
— Accuracy in administering medications improved from an average of 83.8 percent at the start of the program in 2006 to 93 percent after 18 months and 98 percent after 36 months.
— Between September 2006 and September 2009, medication errors at the hospitals dropped by an average of 87.7 percent.
— The adherence to a series of “best practice” principles, which included such techniques as checking two forms of patient identification before administering drugs and explaining each medication to the patient, increased from 79.5 percent at the start of the program to 96 percent after 36 months.
Source: Integrated Nurse Leadership Program
E-mail Victoria Colliver at email@example.com.
October 28, 2009
Prescription for success: Don’t bother nurses
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