January / February 2006
Focus on Legibility
The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines medication error as
...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, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.
In healthcare systems, medication errors are among the leading causes of preventable errors, with a reported inpatient incidence of 5.7% (Kaushal, Bates, Landrigan, et al., 2001). Bates reports that preventable medication errors cost approximately $5,000 per event, with a projected annual cost of $2.8 million dollars for a 700-bed hospital (Bates, Spell, Dullen, et al., 1997). In To Err Is Human, the Institute of Medicine stated that the highest priority for healthcare organizations is medication safety (2000, pg. 27).
Numerous reasons for unsafe medication practices exist, including poor access to information, poor communication, and inadequate knowledge or experience. Information technology may be used to improve safety in hospitals, but it may also contribute to problems. The current nursing shortage and increasing complexity of nursing practice raise the potential for error as clinical demands may exceed even the experienced clinician's capacity to function (Johnson, 2004; Hatcher, et al., 2004).
Common sources of medication errors include writing illegible instructions, accessing the incorrect medication, selecting the wrong doses, failing to check if the medication selected is the correct one, stocking medications in the wrong slot in the dispensing unit, and confusing medications obtained simultaneously for multiple patients.
Study to Find Key Problems
Senior administrators from a multi-hospital healthcare system in the southeastern United States requested a study to determine key drivers contributing to medication errors within their organization. An expert panel consisting of the pharmacy director, staff pharmacist, advanced practice registered nurse, and risk manager was convened to identify process criteria to evaluate compliance with established medication administration procedures. The study focused on seven medication administration processes historically identified by risk management as areas of concern for this healthcare system:
- Legibility of the physician's order
- Legibility of the addressograph information
- Completeness of the physician order for inclusion of the five rights
- Matching the automated medication administration record (AMAR) to the physician's order
- Matching the medication administration time to the PYXIS 30-minute withdrawal time per policy
- Nursing staff verification of transcribed AMAR with the previous day's AMAR
- Handwritten additions accurately reflected the physician's order with the current day AMAR
The sample for this study was limited to a concurrent review of medical records from pediatric patients in the intensive care unit (n=15), four medical surgical units (n=57), telemetry unit (n=18), and neonatal intensive care unit (n=8). The facility is a 132-bed, not-for-profit, acute care children's hospital, which is one of four hospitals in the system.
The hospital's administration expects personnel to achieve a minimum of 85% compliance with all hospital policies and processes. For processes included in the study, in which the expectation was not met, senior managers required the development of action plans. Findings showed statistically significant differences with the following processes:
- Legibility of physicians' medication orders did not meet expectations in any of the hospital units. The percentages by unit were as follows: 13% legibility in the NICU, 53% in ICU, and 28% in telemetry. One medical surgical unit had 80% legibility, and the remaining medical surgical units ranged between 50% and 60%.
- Legibility of the addressograph information on the physician's order sheet. The percentages by unit were as follows: 62% legibility in the NICU, 92% ICU, 80% telemetry, and one medical surgical unit. All remaining medical surgical units ranged between 32% and 65% legibility.
- The AMAR matched the order written by the physician. The percentages by unit were as follows: 75% of the AMARs matched the order written by the physicians in NICU, 93% in ICU, 83% in telemetry, but only 50% of the AMARs matched in one medical surgical unit. Another medical surgical unit had 81% agreement, and the remainder of the medical surgical units ranged between 93% to 100% agreement.
- Nurse verification. According to policy, a registered nurse must verify the correctness of the AMAR with the previous days to ensure that all orders are correctly reflected. The nurses in the NICU validated correctness of the AMAR 100% of the time. None of the other units met expectations, and percentages ranged from 0% to 83% for nurses checking the AMARs.
Illegibility of physician's medication orders has a negative effect on the accuracy of transcribing, dispensing, and administering medication. Conversely, greater legibility of orders can play a major role in error reduction. This information was communicated to the physicians via a presentation at a meeting of the Medical Staff Quality Committee. The vice president of medical affairs initiated a campaign to "call and confirm" rather than to "collaborate with consensus." "Collaborate with consensus" refers to what had been a common practice at this facility: All available staff members looked at an order and attempted to interpret a physician's illegible handwriting. When a consensus was reached, the order was transcribed and implemented. "Call and confirm" refers to the new practice of calling the provider who wrote an original order in question to confirm the order.
Posters with this message were designed and strategically disseminated to remind caregivers of best practice. The pharmacy changed their process by decentralizing pharmacists. A registered pharmacist is based on each of the hospital units between the hours of 7 a.m. and 7 p.m. to review orders when written and enter them into the system. Questions regarding orders may be reconciled "on the spot," prior to the physician leaving the unit.
Legibility of the addressograph information is critical for correct patient identification and location. To ameliorate this problem, the organization decided to purchase new addressographs for each nursing unit so patient information is clearly delineated. Additionally, it was noted that the addressograph imprint plates needed to be replaced regularly in the NICU due to cracking from long-term use.
The computer-automated medication administration record did not always correctly capture new handwritten medication orders from the previous day. The pharmacy initiated a process in which information contained in the medication order entered by the unit pharmacist was double checked by another pharmacist for completeness and correctness. This is a similar process to the nursing department's procedure for having two nurses on different shifts checking each medication order to verify all information is correctly captured.
Ensuring appropriate medication administration is a complex process involving multiple professionals from various disciplines who have drug knowledge and timely access to complete and accurate patient information. Errors may enter into these processes at various points. Many medication errors are preventable, although reducing errors will require multiple interventions.
Donna Lee Ettel (email@example.com) is an associate researcher in Child Health Policy and Outcomes at the University of South Florida. She works in collaboration with All Children's Hospital and the National Initiative for Children's Healthcare Quality on projects to enhance the nation's ability to improve the quality of care for children. Her primary focus is on advancing the use of health information technology applications in child health services through standardization and informing the national agenda to develop electronic health records. Ettel also has worked as director of quality and risk management for large, multi-hospital systems.
Christine Wilson is president and CEO at MARS Consulting, where she oversees clinical research projects and collaborates with senior management and department directors at host facilitates to develop, implement, and evaluate projects and programs that support the organization's mission and strategic direction. She has lectured extensively throughout the United States about clinical issues.
Bates, D. W., Spell, N., Cullen, D., et al., (1997). The costs of adverse drug events in hospitalized patients. Journal of the American Medical Association, 277, 307-311.
Hatcher, I., Sullivan, M., Hutchinson, J., Thurman, S., & Gaffney, F. (2004). An intravenous medication safety system: Preventing high-risk medication errors at the point of care. Journal of Nursing Administration, 34(10), 437-439.
Institute of Medicine. (2000). To err is human: Building a safer health system. L. T. Kohn, J. M. corrigan, & M. S. Donaldson, (Eds.). Washington, DC: National Academy Press.
Johnson, K. B. (2004). Information technology: Its importance to child safety. Ambulatory Pediatrics 4(1).
Kaushal, R., Bates, D. W., Landrigan, C., L., et al. (2001). Medication errors and adverse drug events in pediatric patients. Journal of the American Medical Association, 285, 2114-2120.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). (2005). What is a medication error? Retrieved August 8, 2005, from www.nccmerp.org/aboutMedErrors.html.