Making the Worst 
of a Bad Situation

By Leah Curtin, RN, ScD(h), FAAN, Editor-in-Chief of CurtinCalls, an irreverent, fact-filled scan of nursing and healthcare, Cincinnati, OH; and Roy Simpson, RN, FNAP, FAAN, vice president of Cerner Corp., Kansas City, MO.

So much has been written, shared, advised and imposed about reducing medical errors that the best contribution one can make is to summarize it. First, and despite all the testimony to the contrary, human beings make mistakes. Systems do not. If the system is inadequate or poorly designed, or bypassed or dismantled, poorly programmed or poorly maintained, it is people who have messed up the system.

Now this is not to say that blaming humans is the way to prevent errors. It is not because the more you blame people, or threaten or frighten them, the more likely they are to hide their mistakes. Thus, it seems that we have reached the conclusion that blaming isn’t the best way to handle the problem. Nonetheless, as long as it is people who order, dispense or administer medicines (an Agency for Health-care Research and Quality [AHRQ] study found that medication errors caused one out of five injuries and deaths per year in hospitals) they are most likely to be blamed (disciplined, sued or incarcerated) for making errors. 

Let’s face it, we all make mistakes. But lousy systems, long working hours, inexperience, chaotic working conditions and the like, measurably increase the likelihood that someone will make an error (another AHRQ study demonstrated that errors in prescribing and administering medicines accounted for 56 percent and 34 percent of adverse drug events). So what can be done on the human level to prevent them?

First, let’s talk turkey. A major study (JAMA 1995:274 (1) 35-43) revealed that more than three-fourths of all adverse drug events (errors) resulted from systems errors. Moreover, the kinds of systems that are in need of reform are not the computerized systems, but the human ones. For example, 12-hour shifts are common in today’s hospitals—and I don’t care who likes them and whether they ‘save’ money. I’ll stake my reputation on this: 12-hour shifts increase errors—all kinds of them—and especially medication errors. Requiring those who work 12-hour shifts in hospitals to work mandatory overtime is absolutely begging for an increase in errors.

To anyone who has the audacity to claim that there is no research documenting this increase, I say ‘get a life!’ There are 20 zillion studies documenting the effects of fatigue on performance, concentration, and alertness—ad nauseum.

How long you work is not the only systems error: who is working and how experienced they are also has an impact. While the country was enamored of cross-trained, multi-disciplinary teams (although I found it fascinating that most of the ‘multidisciplinary teams’ consisted of nurses and aides), I could not help but wonder how any team comprised of nothing but utility players could be anything but mediocre at best—and, in our line of work, dangerous at worst! Research studies now confirm the importance of adequate RN staffing to reduce errors.

Skill mix also has been demonstrated to have a direct and measurable impact on patient outcomes—including errors. In addition, stringently limiting ‘cross-training’ and ‘pulling’ nurses to critical care, ED, recovery and pediatrics—in fact, any area that requires familiarity with unusual drugs/dosages—reduces errors (still another AHRQ study found that lack of knowledge of a drug—or a patient—was often a factor in dosage errors).

That being said, how can the human systems be improved?

1. Fully implement a unit dose system for all non-emergency medications. Limit the number of concentrations of high-alert drugs like morphine and heparin, and use premixed solutions whenever possible. Remove concentrated potassium chloride/phosphate from floor stock.
2. Limit to one or two the type of infusion devices/equipment used.
3. Develop/use written protocols for high-alert drugs.
4. Have a pharmacist on-call 24 hours a day or have a 24-hour pharmacy.
5. Standardize prescribing and communication practices—require that the doctor be called if he/she has used any unauthorized abbreviations. No exceptions.
6. Standardize doses, times of administration, packaging and labeling, storage, dosing scales, protocols for the use and storage of high-alert drugs.
7. Revamp punitive approaches to reporting incidents/errors. For example, placing a warning in an employee’s personnel folder (some places put such markers in the personnel files of those who report the error even if they were not the one’s who made the error) may help build a case for terminating him or her, but it also will (not may, will) undermine any system of reporting! 
8. If a hospital is really serious about reporting and tracking errors, it might want to consider the load it places on managers. Management theorists opine that a manager’s average effective span-of-control is 12 direct reports. First-line nurse managers today routinely have upwards of 60 to 100-plus direct reports. Twenty-four hours a day, seven days a week—and often scattered over two or more units and, not uncommonly, located in two or more buildings!

Unless the human systems are under control, the computerized ones can only offer limited help, even though they are a big help, in any case. Any computerized system worth its price will help identify drugs (labeling and bar-coding), transmit orders, document administrations and track adverse events. The features one must look for in a full-service error reduction system include:

• Prescriber order entry (and whether they like it, physicians should enter their own orders—no exceptions. Biometrics can take care of that: A physician can give someone his password, but not his retina.)
• Computer-generated medication administration records
• Bar-coding patients and their drugs
• Computerized drug profiling in the pharmacy
• Computerized tracking of errors
• Root-cause analysis of errors
• Flag charts of patients getting high-alert drugs

All of this is costly, but not nearly as costly as the loss of life, consumer confidence, and malpractice defense and awards…And yet Hospitals & Health Networks (April 2000, page 44) asks “New tools to prevent medical errors are on the market. Why aren’t more hospitals buying in?” Why? Two-Thirds of hospital CEOs and risk managers do not think drug errors are a problem in their hospitals, although 98 percent of them think they are a real problem in other hospitals. Perhaps the most dangerous attitude of all is the one that results from believing your own PR!

© 2000 Nelson Publishing, Inc

July 2000