Medication Errors

Lab Group B

Grace Bryant, John Fernandez, Sydney Freedman, Jenny Lao,

Caitlin Meaney, Samantha Rabb, Danielle Schulz, Alexa Stallworth,
Raquel Trotter
Introduction

Medication errors are prevalent in Quick Facts:

hospitals and prevention is a
Medication errors occur in
significant aspect of the nursing role
about 1 in every 5 hospital
because nurses are often the last medication administrations.
defense to prevent an error.
251,000 deaths each year
3rd major cause of death over
illnesses such as respiratory
However, nurses can often be the disease
perpetrators of medication errors as
well. Interventions can be
implemented to assist in the
prevention of nursing medication
errors.
Objectives

Nursing Practice Issue: medication errors in high acuity settings

Discuss: Our groups analysis of the method of double checking

versus only scanning in the prevention of medication errors,
caused by nurses and other health care workers, in the hospital
setting.

Focus: benefits and disadvantages of two nurse double checking

for high alert medications
 Topic: Prevention of medication errors in high
acuity settings
Population: High acuity patients
Intervention: Dual verification of high alert
medications
Comparison: Single verification of high alert
medications
Outcome: Decrease medication errors by having
dual verification prior to administering high alert
medications
 PICOT Question:

Does dual verification decrease the occurrence of

high alert medication errors in high acuity patients in

comparison to not using dual verification?

Current Practice
Dual verification of medication is a common practice used throughout
hospitals across the country. Selective medications, such as high risk
medications, require two licensed nurses to sign off that the correct
medication and administration occurred

Local
Selective High Alert Medications

Hospital based

Administration

Patient Verification

5 Rights

Independent double check

Current Practice

State
Arizona hospitals have implemented dual verification of hospital
based selective medications
Tucson
St. Joseph Hospital
Tucson Medical Center
Phoenix
Phoenix Childrens Hospital
Gilbert
Dignity Health Mercy Hospital
Sierra Vista
Canyon Vista Medical Center
Current Practice

National
New Zealand

Canada

United States

Malaysia

Taiwan

England

Australia

Scotland
Analysis of Current Research: Current Findings
6 studies suggest double checking reduced medication
errors
1 study argues double checking is helpful for only specific medications
2 studies identify double checks to be effective, but also identify other more
effective interventions
3 studies establish that a two nurse check is effective in preventing med
errors

3 studies indicated limitations with double checks

2 studies suggest unclear guidelines of
double checking
2 studies state training and a dedicated
work environment are required
1 study discusses lack of knowledge and
disruptive environment made double checking
difficult
Strengths of All Studies
Reducing the risk of harm from intravenous potassium
Identified a poor system for potassium administration
Length of 2 years to gather data for study

Comparison of medication safety systems in critical access hospitals

Large multi-center study (12 Nebraska hospitals)
Large sample size (6500 observations)
Studies took into account the patient age, sex, care by nurse, and presence of distractions
during medication administration.

Paediatric nurses understanding of the process and procedure of

double checking medications
All interviews were audiotaped and transcribed, while researchers studied them and identified
patterns.
Unanimous agreement amongst all participants, that double checking should be considered
best practice

Double checking: A second look

Adds to the literature by demonstrating that double checking meds is loosely defined.
Proposes alternative views of double checking to enhance patient safety
Was able to go into a lot of depth with rich descriptions that can be transferred to other
environments
Strengths of All Study
Does an Insulin Double Checking Procedure Improve Patient Safety?
Looked at data from five different units (3 medical and 2 surgical)

Nurses were given a 2-week start-up period to allow nurses to become familiar with the
double checking steps while getting feedback

Randomized and controlled

Medication double-checking procedure in clinical practice: Oncology

nurses experiences
Cross sectional study done in three different hospitals

First investigation into double-checking procedures in cancer care

Gave detailed descriptions of core subprocesses, so everyone had the same understanding
when answering survey questions.

Nurses Knowledge about double-checking process for med

administration
Looked at the opinions of the nurses giving medications

Looked at various units for pediatrics to medical-surgical.

Limitations of All Studies
Reducing the risk of harm from intravenous potassium
Time consuming: relies on the effort of the staff to describe and report incidents, which may
result in an untrue number of incidents.

May need longer duration of study to gather cultural effects

Small uni-site study: unable to determine if the interventions can be translated to other
facilities

Comparison of medication safety systems in critical access hospitals

Using direct observation cannot capture all errors, underestimating the overall error rate

Only used meds given during the morning and afternoon, no meds given in emergency
situations

All the participating hospital were located in the same state, reducing generalizability

Hawthorne effect

Paediatric nurses understanding of the process and procedure of

double checking medications
Has a poor representation of paediatric nurses opinions that are working outside of the
studys hospital settings.

Only 6-7 nurses were used in homogenous groups

The availability of participants and timing of interviews caused the data saturation not to be
achieved
Limitations of All Studies
Double checking: A second look
Only looks at data from one study, and are not generalizable to a variety of contexts
Has a weak evidence base from just one study

Does an Insulin Double Checking Procedure Improve Patient Safety?

Study done in a single-center, cannot generalize to other medical centers

Some nurses may not have followed the intervention protocol fully or failed to record
observed errors.

Medication double-checking procedure in clinical practice: Oncology

nurses experiences
Results may be subject to bias due the the self-reported practices and experiences

Specific steps of double checking procedures in specific units may not have been taken into
account

Nurses Knowledge about double-checking process for med

administratio
Conducted in one hospital, so it can not be generalizable

Relatively low response rate (112 questionnaires and only 48 were returned)

Study occurred at a critical time when the hospital was implementing many changes
Evidence Based Nursing Recommendations

Findings and Conclusions

Double-checking is well-supported
Low-cost strategy
Formal education
Standardized double check process
Provide clarity on best practice
What constitutes a double check?
Which high alert meds require manual double checks?
Realistically achievable guidelines
Reduce complacency, auto-processing, interruptions
Importance of location and design of medication rooms
Evidence Based Nursing Recommendations

Designated distraction-free zones

Quiet
Private
Organized
Adequate space, storage, resources
Additional strategies used in conjunction
Introduction of safety systems
Barcode medication administration
Onsite pharmacist dispensing
Implementation to Nursing Practice
Mandatory paid training clinics
Nurse double-checking contracts
I understand the benefits of nurse double-checking to prevent medication
errors. I understand the new double-check policy. I agree to always be
truthful and ethical in regards to my double-checking and charting. I will
not sign off double-checks that I have not personally and thoroughly
performed.

Paperless charting for double-checks

Double-check overrides - require extra charting and limited per
nurse
Monitoring of new policy
Surveys
Implementation to Nursing Practice
4/1/17 - Present idea and information to the hospital

4/7/17 - Begin to provide education to the hospital staff (mandatory paid learning
clinics); begin creating double-check sign/override system in charting

4/28/17 - All training complete; all nurses have signed double-checking contracts;
double-check sign/override system complete

5/1/17 - New policy for double-checking officially in place; double-check

sign/override system launch

5/7/17, 5/14/17, 5/21/17, 5/28/17 - Weekly monitoring of new policy and charting
system changes

6/1/17, 7/1/17 - Monthly monitoring

12/1/17 - Anonymous surveys regarding double-check policy

Cost Analysis
Monetary Cost:

Component of the average nursing salary in a 12-

hour shift:

Bureau of Labor Statistics Average Hourly Wage for

RNs:

$34.14/hour

Ex. Total time spent double checking is 10-15 minutes

within a 12-hour shift

=double-checking is worth: $5.69-$8.53 per nurse

also take into account cost of overtime/time and a

half wages if medication checks go past 12-hour shift
 Non-Monetary Costs:

Time to double check

Time for extra training and education on high-

alert medications

Availability of Nursing Staff (a registered nurse

always present to assist in checking)
Compare these costs to.

Cost nationwide of medication

errors (16.4 billion annual costs)

Costs of individual hospital

lawsuits

1. Springfield hospital sued for

over $100,000

2. University of Maryland Medical

System sued for $10 million
Risk vs. Benefit Based on Research

Risk:

Inconsistent
expectation for what
constitutes a double
check

Double checking takes

time
8-10 hours lost in a day
on ICU for PCA changes
Risks (continued)

Heavy workload &

quiet environment
makes it less likely for
a check to be
completed
Staff can go through
auto-processing
Diffuses responsibility
for mistakes
Lack of time is biggest
issue
Risk vs. Benefit based on research

Benefit:

Manual double checks

decrease med errors by
10%

In one study, independent

safety checklists and
independent double
checks can completely
prevent ampoule-based
medication errors over the
course of 12 months
Benefits (continued)

When used in conjunction with other forms of double

checking, med errors can be reduced from 0.43 errors per
100 med administrations to 0.05 per 100 med
administrations.

One study reduced 33 annual med error events in 12 months

to 3 med error events annually with other forms of double
checking
SMART Nursing Evaluations

Our PICOT goal:

Decrease medication
errors by having dual
verification prior to
administering high alert
medications
SMART Nursing Evaluations

Is it: a Specific Measurable Attainable Realistic Timely

outcome?

Is it: an evaluation based off of the recommendations

and supported by our research?

Implement Checks
Computerized Checks
Environment
Education
 Research Summary
Medication errors are a significant issue, and Ultimately double
checking is well supported and current practice does verify high acuity
medications.
Data from 6 of the 9 articles fully supports efficacy of double checks.
Limitations in the other 3 were guideline/implementation confusion,
not contradicting use of double checks
Strong studies w/ large studies with large samples, variables take into
consideration, like age and gender, varied units, varied facilities, detail
and unanimously supported either the implementation or further
research
Weak data: time issues, no emergency admin/ error data, not
exhaustive errors, bias, Hawthorn effect.
Monetarily, it is realistic and cost effective compared to error cost
The benefits outweigh the risk, it just difficult to manage time, and
ensure consistent implementation
References
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intravenous potassium: a multi-factorial approach in the haematology setting. Journal of oncology pharmacy practice, 20.
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https://www.bls.gov/oes/current/oes291141.htm

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_in_the_us

Keiffer, S., Marcum, G., Harrison, S., Teske, D. W., Simsic, J. M. (2015). Reduction of Medication Errors in a Pediatric
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