When it comes to prescribing and administering medications, the smallest error could mean the difference between life and death for a patient.
Medications have come a long way over the years and have a huge impact on quality of life. Providers rely on them to prevent, manage and even cure certain diseases and medical conditions. However, we can only achieve these goals when drugs are prescribed, prepared, dispensed and administered safely and correctly.
According to The Centers for Disease Control and Prevention, an adverse drug event causes harm resulting from the use of medication and can include allergic reactions, side effects, overmedication and medication errors. Errors occur due to a breakdown or failure at any point in the medication use process. Medication error is common, and it has significant consequences while also being preventable. The National Academy of Medicine, formerly known as the Institute of Medicine, or IOM, estimates as many as 7,000 people die and 1.5 million people are injured each year from medication errors. These staggering numbers highlight a serious public health problem.
Here at UF Health, Quality is Job 1. We have come a long way in terms of quality improvement and patient safety since first opening our doors in 1958. The way we have addressed medication safety has always been in sharp focus.
A common theme we hear from our faculty and staff is that awareness of risk factors is not enough — we have to be proactive and vigilant. The use of technology has been instrumental in helping us improve patient safety and reduce medication errors. Technology and the patient safety movement have evolved together.
“Medication safety means getting the right drug to the right patient at the right time via the best route of administration,” said Laurie Davies, M.D., UF College of Medicine associate professor of anesthesiology and surgery and UF Health Shands OR medical director. “It means trying to minimize or eliminate patient harm in the event that a drug error is made. It also means being willing to be transparent about errors that are made in order to try to educate others and prevent the same mistake in the future.”
Shifts in Patient Safety
UF was at the forefront of the patient safety movement. The UF College of Pharmacy’s first pharmacy resident, Kenneth Barker, Ph.D., pioneered medication safety in hospital practice while at UF from 1959 to 1961. At that time, hospitals did not commonly record or report medication errors. Barker created a method to observe and measure medication error rates and the subsequent practice of unit dose distribution. He established a new national model for pharmacy operations and error-reduction.
Another critical moment came with the 1999 IOM landmark report, titled “To Err is Human.” This publication brought to light the national effort needed to improve safety in health care, paving the way for moving the focus from errors to improving safe patient care practices and avoiding mistakes.
Medication safety through technology
Over the decades, technological improvements have driven incredible advances in patient safety. Useful interventions that we have implemented here at UF Health include smart infusion pumps, electronic health records and barcode scanning.
Smart Infusion Pumps
Infusion pumps have been in use since the late 1960s, automatically delivering controlled amounts of fluids, such as chemotherapy or antibiotics. Nursing staff would manually enter dosage amounts and delivery rates, leaving more room for user error.
Smart infusion pumps came into play in the early 2000s. Computerized dosing eliminates manual data entry and reduces risk of patient harm.
“We use smart pumps frequently so that medications can be given accurately at the appropriate rate and over the correct duration of time,” Davies said. “In the past, we counted drops and roughly calculated the amount of drug being given.”
When used appropriately, smart pumps can help eliminate catastrophic errors.
“Without this technology, it’s not uncommon to have typing keystroke errors,” said Amy Rosenberg, Pharm.D., BCPS, UF Health Shands Hospital pharmacy specialist in medication safety and quality. “Accidentally adding an extra zero to the dosage amount that should be dispensed is not hard. This pump helps prevent this type of error from occurring.”
Electronic Health Record Technology
Electronic health record technology, known as EHR, became widely used in the early 2000s. EHRs help identify potential medical errors by flagging issues and alerting health care providers. Examples include alerts about possible adverse drug interactions between prescribed and/or over-the-counter medications, a potentially incorrect dose or medications with similar names.
UF Health went live with Epic EHR in 2011, allowing authorized faculty and staff to access their patients’ medical records to support management of their care, including medication management.
These electronic records allow providers to directly submit a prescription order (e-prescribe) to a pharmacy and review details surrounding their patient’s medication history. Having easy access to these records enables providers to make decisions that will help reduce the chance of medication errors. The end result? Improved efficiency and patient safety.
“Before having the EHR, we would perform ‘chart checks’ and reconciliations, not to mention the lost art of decrypting physician handwriting,” said Elizabeth Payne, B.S.N., R.N., RN-BC, UF Health Shands Hospital Medical-Surgical Unit 74 nurse and Patient Safety Nursing Quality Council co-chair. “When I think back to how we did things then and how we do things now, it’s almost mind-blowing.”
One group that benefits from EHR use is surgeons: Having easy access to accurate patient information is integral to protecting their patients’ safety.
Davies, the OR medical director, added, “We embraced technology to try to help us with decision support. For example, having access to Epic helps us easily access the patient’s medication record so we can keep track of when the next dose of a drug, such as an antibiotic, is due.“ It also allows subsequent care providers to see what drugs we have administered in the operating room.”
Barcode scanning increases patient safety by helping staff catch errors at the bedside, helping to ensure patients are safe and receiving the correct medication for their care.
Our hospitals began using barcode scanners in 2014. When a physician prescribes a medication, the pharmacy dispenses it with a barcode label. As the medication is being prepared to administer, the nurse or bedside provider scans both the barcode on the medication packaging and the patient’s wristband to make sure the medication matches what was ordered for the patient.
Davies explains, “In the OR, we use a barcode system that allows us to scan the individual patient’s vial and then prints out a very legible label with the drug name, concentration, date and time. Besides being safer, this labeling and check process also helps us stay compliant with regulatory guidelines.”
Over-Reliance on Technology
Technology has helped improve patient care and decrease medication errors, but we cannot rely on technology alone. Just like human behavior, technology is not perfect. People have a tendency to rely heavily on automated processes, leading them to overestimate their accuracy and performance. Human attentiveness is critical in an industry that is more automated than ever.
According to the Institute for Safe Medication Practices, the use of technology convinces the human mind to hand over tasks and associated responsibilities to automated systems. This mental handover can reduce the vigilance that a care provider would otherwise demonstrate carrying out the particular task independently without technological support.
“Safety technology is great and has improved drastically over the decades,” Rosenberg added from the pharmacy perspective. “But there is great danger in over-relying on technology and just trusting alerts that come our way without using clinical knowledge.”
Relying solely on technology can result in serious consequences — technology is meant to support patient care and clinical thinking, not replace it.
Emphasizing the responsibility for nurses, Payne said, “Research and innovation provide the groundwork for medication safety, but, in my opinion, nurses are at the forefront. We are the last stop before medications reach a patient, and it is our duty to ensure we are giving the right medication to the right patient at the right time in the right way.”
In health care, cultivating an environment of trust and transparency is essential to safeguard patients and ensure high reliability. The Just Culture method, launched at UF Health Shands in 2015, outlines a step-by-step procedure to manage organizational risks and prevent adverse outcomes. The model requires managers to examine the facts of an event without allowing the severity of the outcome to influence their decision as to how to address the situation and those involved.
“In the late 1980s, there was definitely a culture of ‘blame and shame’ in hospitals,” said Sheryl Curtis, M.S.N., ARNP, UF Health Shands Children’s Hospital Pediatrics Unit 44 clinical leader.
“People lived in fear of being written up, and I don’t think medication errors were often trended or that investigations into system errors were explored.”
The Just Culture method ultimately helps faculty and staff foster an even stronger culture of safety and high-quality care.
“Some of the biggest changes I’ve experienced since being with UF Health that have made impacts on our system have included the influence of the Just Culture mindset and the use of patient safety reports, which track and trend medication errors system wide,” Curtis said. “The reports allow changes to be made in the system that will prevent future errors from occurring.”
Moving Medication Safety Forward
When used correctly, medications can make the difference in our patient outcomes and our ability to save lives. Although medication errors are common nationwide, we want to ensure we are taking all available steps to prevent them from happening. At UF Health, we have worked hard to make medication use safe.
When reflecting on how far medication safety has come since UF Health Shands Hospital first opened its doors, it is clear we have helped hardwire and advance crucial quality and safety practices. What’s next?
“I hope to see more logic built into the electronic health record such that suggestions might even be made depending on the context,” Davies said. “For instance, in the OR, if a certain amount of blood loss occurs, the antibiotic concentration in the patient’s bloodstream will decrease, making the patient more susceptible to infection.”
She explains, “We can build logic into the system. We could have a reminder pop up to redose the antibiotic, even when the usual interval for redosing has not elapsed.”
Overall, medication safety will continue to improve with further advances in technology and increased emphasis on medication safety.
It is up to us to continue providing the highest level of quality medical care and best possible experience, and that starts with ensuring safe medication management by faculty and staff.
Payne said, “Collectively we will continue to evaluate trends, areas for improvement and best practices to make medication administration safer for our patients.”
The Five Rights of Medication Administration
According to The Joint Commission, more than 1.5 million preventable adverse drug events occur annually in the U.S. One way to reduce these events involves using the “Five Rights” of medication administration. That includes checking the following:
- Right medication
- Right dose
- Right time
- Right Route
- Right Patient