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In response to "Failure to Report" (March 2007)

June 1, 2007 
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In response to "Failure to Report" (March 2007)


To the editors:

Dr. Spath did an excellent job of using the error as a springboard to explain the importance of an open and sharing environment of error reporting and learning. Although limited details on the error itself were provided, the information that was contained in the case report does give readers an opportunity to more thoroughly review their own systems to discover if an error such as this can happen in their emergency department (ED).

When an error occurs in a situation where nurses may be manipulating a medication in a non-emergency situation before administration, one of the first questions should be, "Why was the nurse put in that position?" Did this ED have 24-hour pharmacy support? If not, was the medication needed when pharmacy was not available? Many hospital departments (including the ED, radiology, and the catheterization area) lack pharmacy support for medication procurement and administration. This is changing—some outpatient practices and many larger hospitals now have satellite pharmacies or have pharmacy prepare all non-emergency medications, an important systems improvement.

Moving upstream, one should ask why prescribers would be ordering commonly used medications by their brand name when generic medications are supplied. Why add the additional step and burden to the nurse to match the brand name to the generic name of the medication? What name is displayed on the automated dispensing cabinet (ADC)? What name is contained on any preprinted order forms that have antibiotics or other commonly used medication in the ED or the hospital? Standardizing order communication around medications, particularly when look- or sound-alike drugs are concerned, should be addressed.

Similar labeling and packaging are a problem with many medications. Unfortunately, because of the many medications that are introduced each year (including the numerous generic versions), the problem will not go away. In fact, when we looked at the graphic of the vials that accompanied the commentary, we felt that the manufacturers had done a fairly good job of differentiating them. The more important question in this case is why the medications were available in near proximity when the cabinet was opened? Did this ADC use a matrix system that allows simultaneous access to several medications rather than one at a time (through the use of individualized, lidded compartments)? If this is the case, then the ADC should be upgraded to have individualized compartments for medications, particularly in areas that lack pharmacy support for dispensing and preparing patient-specific medications. Also, one should ask how the lidocaine is obtained for mixing. Is it also contained in matrix drawers in the cabinet next to other concentrations of lidocaine and/or next to lidocaine/epinephrine mixtures?

Finally, independent double-checks at the bedside or point-of-care barcode systems are other potentially useful strategies to safeguard drug administration. ED staff should consider using independent double-checks for medications taken from storage and prepared without pharmacy oversight, particularly in known high-risk populations such as pediatrics, where the margin of error is so small and results can be quite harmful.

Even in organizations with an open and sharing environment of reporting errors, unless some basic systems issues (such as these and those presented by Spath) are addressed, learning and proactive error prevention will be set back.

Allen J. Vaida, PharmDSusan Paparella, RN, MSNInstitute for Safe Medication Practices

In reply:

I appreciate that Vaida and Paparella have built on my commentary, which emphasized why mistakes may not be acknowledged or reported and suggested strategies for reversing this situation, by adding a number of other good ideas for systems changes. Several of these ideas have been long-standing suggestions of groups concerned with medication safety, including their organization (ISMP) and the American Society of Health-System Pharmacists. This of course raises a question: Why haven't health care organizations already adopted these ideas? Some interventions require additional resources, which could be an inhibiting factor. However, many tactics—such as not storing similarly named drugs in close proximity—often take little more than will and action.

Failing to recognize mistakes contributes to organizational inertia and individual complacency. In the absence of open discussion and reporting, leaders and front-line providers ask—why implement even the most basic safety recommendations when the current systems and processes of care appear to be working well? This false sense of security impedes safety improvements.

To make health care safer, we need an understanding of what causes mistakes and good ideas on how to prevent system-induced errors. But just as important is the willingness of organizations and individuals to take proactive, preventive measures. Acknowledging and reporting mistakes create the needed catalyst for this willingness.

Patrice L. Spath, BA, RHITBrown-Spath & Associates

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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