The Nurse's Role in Medication Safety, 2nd Edition

The Nurse’s Role in Medication Safety, Second Edition

Edited by
Laura Cima, R.N., B.S.N., M.B.A., N.E.A.-B.C., F.A.C.H.E.
and
Sean Clarke, R.N., Ph.D., F.A.A.N.
Written especially for nurses in all disciplines and health care settings, this second edition of The Nurse’s Role in Medication
Safety focuses on the hands-on role nurses play in the delivery of care and their unique opportunity and responsibility to
identify potential medication safety issues. Reflecting the contributions of several dozen nurses who provided new and
updated content, this book includes strategies, examples, and advice on how to:
• Identify and correct repetitive medication error patterns and ensure a safe and just culture for error reporting The
Nurse’s
• Facilitate patient and staff education on the special risks of high-alert medications.
• Apply teamwork, communication, and human factors solutions to medication management issues
• Support the frontline role of nurses in safer medication administration by reducing disruptive behavior and other
interruptions
• Use technology (such as smart pumps and computerized prescriber order entry) to improve medication safety
Role in
• Develop effective medication reconciliation processes across the continuum of care and especially for transitions of care
• Implement a risk management process to prevent and investigate medication errors
• Recognize the special issues of medication safety in disciplines such as obstetrics, pediatrics, geriatrics, and oncology
and in program settings beyond the large urban hospital, including long term care, behavioral health care, critical access
and rural hospitals, home care, and ambulatory care
Second Edition
About Joint Commission Resources
Medication
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to assist in improving quality and safety and to help in meeting the accreditation standards of The Joint Commission. JCR
provides consulting services independently from The Joint Commission and in a fully confidential manner. Please visit our Web
site at http://www.jcrinc.com.
Safety
About Joint Commission International
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organizations, government agencies, and third party payers throughout the world. It provides educational services, consulting
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quality and safety of health care organizations.
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on Accreditation of Healthcare Organizations to provide leadership in health care accreditation and quality improvement.
Please visit our Web site at www.jointcommissioninternational.org.

Edited by
Laura Cima, R.N., B.S.N.,
M.B.A., N.E.A.- B.C., F.A.C.H.E.
Item Number: NRMS11
and
Sean Clarke, R.N., Ph.D., F.A.A.N.
Editor: Lisa Abel
Project Manager: Bridget Chambers
Associate Director, Production: Johanna Harris
Executive Director: Catherine Chopp Hinckley, Ph.D.
Joint Commission/JCR/JCI Reviewers: Pat Adamski, Ann Jacobson, Ali Malik, Maureen Carr, Jeannell Mansur, Nanne Finis,
Cynthia Leslie, Mark Pelletier, Margherita Labson, Dana McGrath, Nancy Gorman, Catherine Hinckley
External Reviewer: John Gosbee
Joint Commission Resources Mission

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person should be sought.
© 2012 Joint Commission Resources, Inc., Compl.

© 2012 Kaiser Permanente, Chapter 1
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CONTENTS
Foreword vii
AUTHORS: Laura E. Cima, R.N., M.B.A., N.E.A.-B.C., F.A.C.H.E., Vice President, Clinical Operations,
Hackensack University Medical Center, Hackensack, New Jersey; and Sean P. Clarke, R.N., Ph.D., F.A.A.N., R.B.C.
Chair in Cardiovascular Nursing Research, University of Toronto and University Health Network, Toronto, Canada
Introduction 1
Chapter 1. Medication Safety: Reducing Error Through Improvement Programs 5

AUTHORS: Kaiser Permanente Northern California—Suzanne Graham, R.N., Ph.D., Regional Executive Director
of Patient Safety and member of The Joint Commission Patient Safety Advisory Group; Molly Clopp, R.N., M.S.,
M.B.A.T.M., Regional Strategic Leader, Patient Safety; Barbara Crawford, M.S., R.N., N.E.A.-B.C., Regional Vice
President, Quality and Regulatory Services; Doug Bonacum, M.B.A., C.S.P., Program Office Vice President, Safety
Management; Becky Richards, R.N., M.A., D.Mc., Adult Clinical Service Director, Modesto Medical Center; Celia
Ryan, M.S.H.A., R.N., C.P.H.Q., Area Quality Leader, Fresno Medical Center; Nicholas Kostek, R.Ph., M.S., Regional
Pharmacy Quality/Patient Safety Coordinator; and Rebecca Lalonde, R.N., M.B.A., Area Quality Leader, Santa Rosa
Medical Center
FOCUS: High-Alert Medications: Opioids in Home Care, Hospice, and

ө
Behavioral Health Care Settings 31
Chapter 2. Medication Safety: Using Technology 35

AUTHORS: Brigham and Women’s Hospital, Boston—Anne D. Bane, R.N., M.S.N., Director, Clinical Systems
Innovations, Center for Nursing Excellence; Carol J. Luppi, R.N., B.S.N., A.L.M., Nurse Educator for Technology,
Center for Nursing Excellence; Laura Mylott, Ph.D., R.N., Director of Nursing Education, Innovation, and Evidence-
Based Practice, Center for Nursing Excellence; and Patrice K. Nicholas, D.N.Sc., M.P.H., R.N., A.P.R.N., B.C., F.A.A.N.,
Director of Global Health and Academic Partnerships, Center for Nursing Excellence, and Professor, MGH Institute of
Health Professions Graduate Program in Nursing
FOCUS: Technology: Benefits of Telemonitoring in Home Care 57
iii
Chapter 3. Medication Reconciliation: Lessons Learned 59

AUTHORS: Our Lady of Lourdes Memorial Hospital in Binghamton, New York—Caryl Ann Mannino, R.N., B.S.N.,
O.C.N.®, N.E.-B.C.; Anita Markovich, R.N., B.S.N., M.S.N., M.P.H., C.P.H.Q.; and Deborah Mican, R.N., B.S.N.,
M.H.A., C.N.O.R.
FOCUS: Transitions in Care: Communication of Medication Information

Between Health Care Settings 76
FOCUS: Patient Education: Addressing Low Health Literacy Among

Home Care Aides 79
Chapter 4. Medication Errors: Risk Management 81

AUTHOR: Grena Porto, R.N., M.S., A.R.M., C.P.H.R.M., Principal, QRS Healthcare Consulting, LLC,
Hockessin, Delaware, and member of The Joint Commission Patient Safety Advisory Group
FOCUS: Technology: Using Telepharmacy and PIS to Reduce Risks for

Medication Error in Critical Access Hospitals and Rural Hospitals 97
Chapter 5. Medication Safety: Considerations for Pediatrics 101

AUTHOR: Ronda G. Hughes, Ph.D., M.H.S., R.N., F.A.A.N., Associate Professor, Marquette University, Milwaukee
FOCUS: Patient Education: Educating Parents About Their Children’s Medications

in Ambulatory Care 109
Chapter 6. Medication Safety: Considerations for Geriatrics 111

AUTHOR: Trish O’Keefe, R.N., M.S.N., Morristown Memorial Hospital, Morristown, New Jersey
FOCUS: Staff Education: Medication Technicians in Long Term Care 120
FOCUS: High-Alert Medications: Antipsychotic Medications in

Long Term Care 122
iv
CONTENTS
Chapter 7. Medication Safety: Considerations for Obstetrics 125

AUTHORS: Mary C. Brucker, C.N.M., Ph.D., F.A.C.N.M., Louise Herrington School of Nursing, Dallas; and
Tekoa L. King, C.N.M., M.P.H., F.A.C.N.M., University of California, San Francisco, and Deputy Editor, Journal
of Midwifery and Women’s Health
FOCUS: Patient Education: Educating Parents About Infant Formula

Preparation 140
Chapter 8. Medication Safety: Considerations for Oncology 141

AUTHOR: Kristen Maloney, M.S.N., R.N., A.O.C.N.S., Hospital of the University of Pennsylvania, Philadelphia
FOCUS: High-Alert Medications: Oral Chemotherapy Outside the

Hospital Setting 150
Index 153
v
FOREWORD
Bill, a 58-year-old male in excellent health, is At 4:00 A.M. the following morning, his wife receives
admitted to the hospital for a knee replacement. a phone call from the nurse at the rehabilitation
The surgery goes well, without complication, and facility: “We are taking your husband to the near-
all expect a smooth postoperative course in the est hospital. He is having difficulty breathing and
acute care setting, followed by a short stay in a his blood pressure is dropping.” His wife meets him
rehabilitation facility. in the emergency room at the hospital. It’s obvious
from his appearance that he is critically ill. Initial
Postoperatively, Bill develops bilateral deep vein laboratory tests reveal an INR of 4 and hemoglobin
thrombosis, and the surgeon and staff suspect pul- of 5.7. Diagnosis: massive retroperitoneal bleed,
monary emboli. He is started on intraveneous (IV) secondary to enoxaparin sodium overdose. He is
heparin and does well throughout the remainder of admitted to intensive care, where he stays for four
his acute care stay. On day 4, he is transferred to a days, during which time he is transfused with 11
rehabilitation facility, although his preference is to go units of blood and 8 units of fresh frozen plasma.
home. His wife (who is a nurse) and physicians insist He is seen by multiple physician specialists because
on the rehabilitation facility because of the intense the hemorrhaging has caused his organs to shift. In
physical therapy that will be available to him there. addition, he undergoes surgery for a Greenfield fil-
He reluctantly agrees. ter because he can no longer take anticoagulants.
ө
He is finally transferred to a medical/surgical unit.
He is transferred to the rehabilitation facility with After two days, he is discharged home. Thankfully,
standard admission orders for activity, diet, and so he has no residual physical effects. The cause of this
on. He has left the acute care hospital on enoxapa- emergency: The order to discontinue the enoxapa-
rin sodium (low molecular weight heparin) and his rin sodium when the INR was 2 was missed; that
usual antihypertensive medication. An order was is, the order was transcribed, but the enoxaparin
written in the chart to discontinue the enoxaparin sodium was never discontinued when the INR was
sodium when the INR (International Normalized 2, as the physician ordered.
Ratio) is 2. Days 1 and 2 at the rehabilitation
facility are relatively uneventful, although Bill The psychological fallout of this episode on
does not have his typical appetite and complains both the patient and his family was incalcu-
of some “stomach discomfort.” On day 3, he has lable. Bill and his family are now skeptical
eaten essentially nothing, refuses to get out of bed, and mistrusting of the health care system. Bill
and continues to complain of stomach discomfort. claims he will never go back to a hospital again
An abdominal flat plate reveals no significant because they [the staff] “almost killed” him. He
findings. He wants to go home because he will feel is correct. His wife and one of his daughters,
more comfortable there, and safer. However, it is a who is a nurse like her mother, gained a first-
holiday and most pharmacies are closed. He needs hand appreciation of medication errors and
his prescription for pain medication (for the knee their impact from the client’s side. The finan-
replacement) filled, so he and his wife decide to cial impact of this error: more than $100,000 in
wait until morning and she will pick him up. unexpected medical bills.
vii
The Issue of Errors additional costs connected with the treatment

of a number of conditions not present at the
The error described previously hits rather time of a patient’s admission—those that were
close to home. The patient who experienced acquired during the patient’s hospital stay
it is a family member of one of the editors of and were likely preventable. These events
this book. The need for safer medication man- include foreign objects retained after surgery,
agement practices became crystal clear to all air embolism, blood incompatibility, Stage III
associated with this error. Bill was fortunate. and IV pressure ulcers, falls or trauma result-
According to the physicians who cared for him ing in serious injury, and catheter-associated
after this incident, had he not been in such vascular and urinary tract infections. Expected
good physical condition before these events, to join this list soon are surgical site infections
he never would have survived this error. following specific elective procedures, includ-
ing certain orthopedic and bariatric surgeries;
This case is an example of just one of the certain manifestations of poor glycemic con-
many types of medication errors that occur trol; and deep vein thrombosis or pulmonary
daily in health care settings, resulting in thou- embolism following total knee replacement
sands of injuries and deaths and millions of and hip replacement procedures.3 Interest-
dollars in additional expenditures. For payers, ingly, the issue of medication errors has yet
this problem represents a huge generator of to be addressed by the CMS, but given the
unnecessary and wasteful spending of scarce frequency of these errors and expenses con-
health care dollars. To the organizations where nected with them, similar measures excluding
errors occur, errors represent a public rela- reimbursement are likely on the horizon.
tions problem, lost revenue, and even legal
exposure problems. For health care providers, The press releases around the often-cited
this statistic and the underlying problem raise 1999 Institute of Medicine (IOM) report To
deep concern and discomfort. And to consum- Err Is Human emphasized an estimate of the
ers of health care—the most important stake- death toll from medical errors in U.S. hospi-
holders here—the problem and its magnitude tals as high as nearly 100,000 per year. Not
are absolutely frightening. surprisingly, this report created a media frenzy
and led to patient safety issues skyrocketing
It’s no wonder that the Centers for Medicare to the top of agendas for health care provid-
& Medicaid Services (CMS) has focused its ers, payers, and consumers. Since the publi-
attention on patient safety issues. The total cation of that report, many safety experts have
cost for medical errors was estimated at $19.5 expressed skepticism that much progress has
billion in 20081; and as of 2006, it was esti- been made to improve patient safety in hospi-
mated that medication errors alone could result tals.4 More recently, an IOM report synthesiz-
in as much as $3.5 billion in additional medi- ing research and expert opinion settled on an
cal expenses in the United States. This figure estimate of one medication error per patient
is admittedly rough, and does not include, for per day of hospitalization.5 Today, despite all
instance, the lost wages and productivity of of the steps taken to avoid medication errors,
individuals requiring additional medical inter- patients and families still enter the U.S. health
vention.2 In its role as a leading health care care system fearful that there will be a mistake
payer, the CMS is at the forefront of efforts in their care, particularly related to the medi-
to advance patient safety by using incentives cations they receive, or worse—that they will
related to payment of hospitals to drive bet- become a statistic or a news story. Medication
ter practices. As of October 2008, hospitals safety is a concern globally as well, with hos-
are no longer reimbursed by the CMS for pital medical, nursing, and pharmacy leaders
viii
FOREWORD
around the world working in cooperation and involve more than one health discipline, and at
bringing in other disciplines to advance safer each step there is potential for error:
medication practices. 1. Procurement
2. Storage
3. Prescribing
4. Repackaging
More recently an IOM
5. Transcription
report synthesizing
6. Preparation
research and expert
7. Dispensing
opinion settled on
8. Administration
an estimate of one
9. Monitoring
medication error per
patient per day of
The safety of patients receiving drug therapy
hospitalization.5
is contingent on diligence and interdisciplin-
ary collaboration within each step of a medi-
cation management system. Gosbee and
The Probability of Errors Gosbee, in their book Using Human Factors
Why do medication errors still plague health Engineering to Improve Patient Safety, recom-
DEFINED: Medication Errors,
care systems around the world? James Rea- mend that health care leadership adapt the
ADEs, and ADRs
son, a safety expert, has pointed out that human factors engineering (HFE) philosophy
Medication errors are not the
basic probability theory tells us that processes to the issue of patient safety, a move that is same as adverse drug events
involving complex chains of tasks (such as needed to overcome the “blame and shame” (ADEs) or adverse drug reactions
safe delivery of drug therapy to hospitalized attitude.7 Rather than look at individuals who (ADRs). The following definitions
patients) are doomed to fail on a regular basis are involved in an adverse event, HFE looks clarify the distinctions among
unless errors are trimmed down to the very at the system failures behind the event to these terms10:
smallest levels in each of the component pro- develop long-term, lasting resolution. “A • An ADE is harm caused by a
drug (adverse drug reactions
cesses.6 A task containing 40 elements, each poorly designed system,” according to Laura
and overdoses) or from use
of which is completed with 95% accuracy, will Lin Gosbee, “is one that does not match the of the drug (dose reductions
be totally successful only 12% of the time. needs of the human or task or does not take and discontinuations of drug
Given enough steps, any process will break into account human limitations.”8(pp. 4–5) She therapy).
down in time. Even when each step is com- adds that among the human characteristics • An ADR is a harmful
pleted with 99.99% accuracy, a process with that have limitations are perception, memory, response to a drug taken
100 steps will run into at least one problem at and anthropometrics. Human capabilities and normally at normal doses.
• Medication errors are
least 1 in 100 times. limitations include such concerns as physical
mistakes that occur during
limitations, posture and movement, fatigue
prescribing, transcribing,
Errors in the Medication Management and sleep deprivation, environmental factors, preparing, administering, or
Processes and cognitive limitations.8 All of these phenom- monitoring of a drug. Medica-
Every step in a medication management system ena must be considered in designing effective tion errors do not necessarily
plays a role in getting the right medication to the and safe systems. result in an ADE.
right patient at the right time by the correct route.
Although some minor details may be altered by Causes of Errors
newer technologies, the essence of the process Patient safety experts have concluded that
has not remained constant. Process experts medication errors happen for a number of rea-
have identified at least nine distinct steps in sons, but the most common causes include
medication management,* many of which the following9:
* The Joint Commission also identifies distinct parts of a medication management system, each of which has stan-
dards defined to meet accreditation requirements.
ix
• Poor communication, such as incomplete medication regimens. The responsibility carried

patient information, illegible handwriting, or by nurses is indeed weighty, and the nurse’s
miscommunication of drug orders role in medication safety is a challenging one
• Ambiguities in product names, dosing units, never to be taken lightly.
or medical abbreviations
• Lack of appropriate labeling The Second Edition
• Environmental factors, such as lighting,
heat, noise, and interruptions This second edition of the The Nurse’s Role
• Patient misuse because of poor under- in Medication Safety updates and expands on
standing of the directions for use of the the concepts of the first edition and provides
medication an international perspective on medication
safety practices as well. In this edition, read-
The Nurse’s Role—And ers can consider anew the ever-growing avail-
ability of technology and its implications for the
Responsibility nurse’s role in medication safety. They can get
The process of preventing errors and address- fresh insight into risk management concerns
ing the reasons they occur requires vigilance with medication administration and subse-
as well as consistent and systematic double- quent errors. The needs of the special popula-
checking throughout the medication manage- tions in geriatrics, pediatrics, and oncology, as
ment process. As noted above, medication well as the obstetric dyad of mother and fetus
management must be driven by the objective are highlighted. Woven throughout the discus-
of patient safety. For nurses, this objective sions are best practices and error-avoidance
must be pursued in collaboration with other strategies in medication management, all
disciplines, specifically physicians and other offering new perspectives on familiar con-
prescribers, as well as pharmacists and nurs- cepts. It is our hope that this book will prove
ing colleagues. Even with increased standard- helpful to nurse leaders and nursing staff, as
ization of drug ordering, computerized delivery well as their colleagues, who are such criti-
systems, and bar coding, nurses must feel com- cal links in the chain of medication manage-
fortable raising concerns and asking for clarifi- ment. Our goal is to help you, your colleagues,
cations about orders that do not make sense to and your institutions achieve safer medication
them. Although members of any discipline can management systems and to reduce the num-
make mistakes in the chain of steps in the med- ber of stories like Bill’s.
ication management process, nurses—who
are at the “sharp end” of the process—have Laura E. Cima, R.N., M.B.A., N.E.A.-B.C.,
a unique role in preventing medication errors. F.A.C.H.E., Vice President, Clinical Opera-
They are usually the last individuals who stand tions, Hackensack University Medical Center,
between the medication and the patient. They Hackensack, New Jersey
must be conversant with an ever-increasing
array of medications, some of which are highly Sean P. Clarke, R.N., Ph.D., F.A.A.N., R.B.C.
toxic, such as chemotherapeutic agents. They Chair in Cardiovascular Nursing Research,
must be acutely aware of all aspects of drug University of Toronto and University Health
safety: safe dosages, safe and appropriate dilu- Network, Toronto, Canada
ents, and medication side effects and signs of
overdosing, as well as look-alike/sound-alike References
medications. And they must be willing and able 1. Hobson K.: Study puts cost of medical errors
to educate patients and their families about at $19.5 billion. Wall Street Journal Health
x
FOREWORD
Blog, Aug. 9, 2010. http://blogs.wsj.com/ 7. Gosbee J.W., Gosbee L.L. (eds.): Using Human
health/2010/08/09/ (accessed May 30, 2011). Factors Engineering to Improve Patient Safety:
2. National Academy of Sciences, National Problem Solving on the Front Line, Second
Academy of Engineering, Institute of Medi- ed. Oakbrook Terrace, IL: Joint Commission
cine, National Research Council: News from Resources, 2010.
the National Academies. Jul. 20, 2006. http:// 8. Gosbee L.L.: Theory and general principles. In
www8.nationalacademies.org/onpinews/ Gosbee J.W., Gosbee L.L. (eds): Using Human
newsitem.aspx?RecordID=11623 (accessed May Factors Engineering to Improve Patient Safety:
18, 2011). Problem Solving on the Front Line, Second
3. Managed Care First Report: CMS the Latest to ed. Oakbrook Terrace, IL: Joint Commission
Deny Payment of Hospital-Acquired Conditions. Resources, 2010, pp. 4–5.
2011. http://www.mccfirstreport.com/ 9. U.S. Food and Drug Administration:
show_story.php?newsid=6697 (accessed Medication Errors. http://www.fda.gov/
May 21, 2011). drugs/drugsafety/medicationerrors/
4. HealthGrades, Inc.: HealthGrades Quality Study: default.htm (accessed Aug. 23, 2011).
Patient Safety in American Hospitals. Denver: 10. Veterans Affairs Center for Medication Safety
Health Grades, 2004. and Veterans Health Administration Pharmacy
5. Aspden P., et al. (eds.), Committee on Iden- Benefits Management Strategic Healthcare
tifying and Preventing Medication Errors, Group and the Medical Advisory Panel: Adverse
Institute of Medicine: Preventing Medication Drug Events, Adverse Drug Reactions and
Errors, Quality Chasm Series. Washington, DC: Medication Errors: Frequently Asked Questions.
National Academies Press, 2007. Nov. 2006. http://www.pbm.va.gov/vamedsafe/
6. Reason J.: Managing the Risks of Organizational Adverse%20Drug%20Reaction.pdf (accessed
Accidents. Aldershot, UK: Ashgate Publishing, Jul. 12, 2011).
1997.
xi
INTRODUCTION
Nurses are the last discipline in the chain of (wherever they may practice) to help create a
medication administration. This places them safer health care environment.
in a pivotal position in medication manage-
ment and error avoidance. Often, the indi- Purpose of This Book
vidual responsible for the medication error
becomes the focus of the event, usually with The purpose of the second edition of The
a re-education plan or a disciplinary process Nurse’s Role in Medication Safety is to
as the intervention. However, this practice enhance the concepts of medication safety
just diverts leadership’s attention from the practices presented in the first edition. The
true culprit of the error, the systems and pro- authors and nurse researchers have provided
cedures established for medication manage- multiple evidence-based practices on a num-
ment. Because they are in this key role of ber of topics related to medication manage-
administering medications, nurses have many ment processes and procedures, all aimed
opportunities to assess, analyze, and provide at assisting nurses to improve systems in the
feedback regarding those systems in order to organizations in which they practice in order
prevent medication errors and improve pro- to create safer environments. In addition, this
cesses. One such approach is filing incident book provides an international perspective on
ө
reports or unusual occurrence reports that can this important patient care issue.
provide useful trending information on medi-
cation errors or “close calls” (“almost errors”) In brief, the book offers advice from nurse
and drive needed changes in medication man- experts and nurse researchers on the role of
agement processes, policies, and procedures. nurses as it pertains to the following topics:
However, historically, nurses completing inci- • The importance of implementing medica-
dent reports have feared punishment and ret- tion safety improvement programs that
ribution by managers and peers. Still others reflect an understanding of human factors
have questioned the real impact on care and and promote a safe, just culture
whether, particularly in the face of overwork, • The technology available to enhance
the time invested in completing reports is safety in medication management and
worthwhile. recommendations for nurses in the use of
technology
Nurses, as patient advocates, can do much • The lessons learned from medication
to make health care institutions safer for reconciliation processes and tips to
patients. Nursing research, education, and the improve the processes
implementation of best practices will help this • Risk management concerns and recom-
cause. Strong collaborative relationships with mendations for investigating the cause of
physicians and other providers, pharmacists, medication errors
nursing colleagues, and leadership are a must • Medication safety issues in selected clini-
in the quest for patient safety. In addition, it is cal populations: pediatrics, geriatrics,
the responsibility of nurses as practitioners obstetrics, and oncology
to share best practices with their colleagues
1
• Medication safety issues in selected clinical Chapter 3. Medication Reconciliation:

settings: long term care, home care, ambu- Lessons Learned
latory and office-based surgery, behavioral The lessons learned from medication reconcil-
health care, and critical access hospitals iation processes are the topic of this chapter.
Recommendations from several agencies con-
Overview of Contents cerned with patient safety, such as The Joint
Commission, the World Health Organization,
Chapter 1. Medication Safety: Reducing and the Agency for Healthcare Research and
Error Through Improvement Programs Quality, are drawn upon in discussions about
This chapter, contributed by authors from Kai- accurate medication reconciliation to promote
ser Permante Northern California, discusses patient safety. Strategies for error avoidance
the many issues involved in implementing through appropriate medication reconcilia-
successful medication safety programs. The tion procedures are emphasized as critical
High-Alert Medication Program (HAMP), throughout the continuum of care. Approaches
a multidisciplinary approach to medication to medication safety by the leadership at Our
administration developed by a team at Kaiser Lady of Lourdes Hospital in Binghamton, New
Permanente, is reviewed and offered as a pro- York, are presented as best practices.
cess to avoid drug errors. Human and environ-
mental conditions that contribute to medication Chapter 4. Medication Errors: Risk
errors are discussed, including the impact of Management
disruptive behavior and interruptions to the Chapter 4 addresses why medication errors
medication nurse. The role of technology and continue to happen despite the steps that
the value of an ongoing education program to have been taken to prevent them. Incor-
address errors are also addressed, as is ensur- rect approaches and the reasons why these
ing a safe and just culture for error reporting. approaches are incorrect are discussed. The
The result of the multipronged approach at author discusses the effective risk manage-
Kaiser has led to positive culture changes and ment approach, identifying each component
a safer medication administration process in as well as tools that may be used in each.
which nurses actively participate. Appropriate investigative processes to deter-
mine the reason(s) for error are outlined as
Chapter 2. Medication Safety: Using well, providing nurses with a comprehensive
Technology approach to understanding why errors occur
In Chapter 2, nurse leaders at Brigham and in their organization. An eight-step process
Women’s Hospital in Boston discuss the role for implementing risk-reduction strategies
of technology in creating safer medication provides a guide for nursing leaders to begin
administration processes, including the use analyzing processes to create a safer patient
of computerized provider order entry and environment.
protocol-based checklists in concert with per-
formance improvement techniques. Each step Chapter 5. Medication Safety:
of medication management is addressed from Considerations for Pediatrics
the standpoint of available technology. The Pediatrics, one of the most vulnerable of popu-
importance of nurse involvement in the selec- lations, is addressed in terms of appropriate
tion and design of new technologies—and ordering of medications and calculations of
education about those technologies—is also doses. Factors influencing medication safety
emphasized. and incidence of errors (calculation, skill of
practitioner, and organizational issues) are
presented in this chapter, with strategies to
2
INTRODUCTION
prevent errors in this population offered to more urban or larger hospitals and hospital
nurses practicing in this environment. systems may not have. Nurses in these set-
tings need to be just as vigilant in preventing
Chapter 6. Medication Safety: errors as providers in the hospital setting. Fol-
Considerations for Geriatrics lowing each chapter is a “Focus” feature that
The growing geriatric population and the highlights a medication safety issue in one or
issues of side effects of medications and poly- more of these settings as it relates to high-alert
pharmacy are addressed. The Beers Criteria medications, technology, transitions in care, or
are discussed as a best practice to ensure patient and staff education. The information in
safe geriatric medication management. Nurs- these brief features may, in addition, help sup-
ing strategies related to medication manage- port nurses across the continuum of care to
ment for the geriatric population are offered. reduce the risks of medication errors.
Chapter 7. Medication Safety: Terms Used in This Book

Considerations for Obstetrics This book addresses both general and spe-
This chapter addresses medication issues in cific health care settings. For general discus-
obstetrics. Also emphasized is the transmis- sions, the term patient will be used to discuss
sion of medication through breast milk, the the care recipient. In cases in which a specific
impact of medication administered at different setting is discussed, the care recipient will be
stages of pregnancy—prenatal, intrapartum, addressed with terminology appropriate for
and postpartum—and potential threats to the the setting. For example, patient will be used
mother and fetus. These discussions offer the for hospital, ambulatory care, and home care
nurse an overview of medication safety in this settings; individual will be used for behav-
population. ioral health care settings; and resident will
be used for long term care settings. The term
Chapter 8. Medication Safety: health care in this book refers to all types of
Considerations for Oncology care, treatment, or services provided within
The high-alert class of antineoplastic medi- the spectrum of the health care field, includ-
cations are a mainstay of treatment for this ing physical, medical, and behavioral health
patient group. Safer and best practices are care.
discussed that address look-alike/sound-alike
medications, nursing education, and the When Joint Commission standards that apply
involvement of patients and families in medi- to multiple program settings are quoted in this
cation safety. book, the term organization will represent any
specific program setting (for example, hospi-
Focus Features tal) in the original program standards text.
Although medication errors or adverse drug
events (ADEs) are more researched and pub- Acknowledgements
licized in the hospital setting, they can occur Publications of this nature are the result of the
just as easily and commonly in settings out- important contributions of many individuals.
side the hospital, such as in ambulatory care Joint Commission Resources (JCR) is grate-
and stand-alone surgical facilities or surgery ful to all of those who contributed to the suc-
centers, behavioral health care, home care, cess of this book. We are particularly grateful
and long term care organizations. They can to this edition’s content editors: Laura E.
also occur in rural and critical access hospi- Cima, R.N., M.B.A., N.E.A.-B.C., F.A.C.H.E.,
tals, which, although hospitals, may have spe- Vice President of Clinical Operations, Hacken-
cial needs for medication management that sack University Medical Center, Hackensack,
3
New Jersey; and Sean P. Clarke, R.N., Ph.D., the chapters. JCR is also grateful to the mul-
F.A.A.N., R.B.C. Chair in Cardiovascular Nurs- tiple reviewers and content experts for their
ing Research, University of Toronto and Uni- feedback to ensure that the overall content
versity Health Network, Toronto, Canada. We is accurate and relevant to the various health
also greatly appreciate all the authors who care settings. Those reviewers are listed on
shared their experiences in developing strate- the copyright page. Special thanks goes to
gies to help nurses improve medication safety. Jeannell Mansur, Joint Commission Practice
And many thanks go to Meghan Pillow, a Leader in Medication Safety, for her thorough
nurse and freelance writer/editor, for her work reviews, which improved the book throughout
on the “Focus” features that appear between its development.
4
MEDICATION SAFETY:
CHAPTER ONE Reducing Error Through
Improvement Programs
AUTHORS: Kaiser Permanente Northern California—Suzanne Graham, R.N., Ph.D., Regional Executive
Director of Patient Safety and member of The Joint Commission Patient Safety Advisory Group; Molly Clopp,
R.N., M.S., M.B.A.T.M., Regional Strategic Leader, Patient Safety; Barbara Crawford, M.S., R.N., N.E.A.-
B.C., Regional Vice President, Quality and Regulatory Services; Doug Bonacum, M.B.A., C.S.P., Program
Office Vice President, Safety Management; Becky Richards, R.N., M.A., D.Mc., Adult Clinical Service Director,
Modesto Medical Center; Celia Ryan, M.S.H.A., R.N., C.P.H.Q., Area Quality Leader, Fresno Medical Center;
Nicholas Kostek, R.Ph., M.S., Regional Pharmacy Quality/Patient Safety Coordinator; and Rebecca
Lalonde, R.N., M.B.A., Area Quality Leader, Santa Rosa Medical Center
According to the Institute of Medicine’s 2006 blaming, and shaming. The chapter will begin
report Preventing Medication Errors, 380,000– with background on a medication safety pro-
450,000 preventable adverse drug events gram focused on high-alert medications that
(ADEs) occur in hospitals each year (most fre- was developed by Kaiser Permanente North-
quently in medication prescribing and adminis- ern California (KPNC). The bulk of the chap-
tration).1 In an industry filled with professionals ter will elaborate on various considerations
who go through intense medical training and involved in designing and implementing medi-
are carefully screened for their positions, why cation safety improvement programs like that
ө
is health care so dangerous? The first thing we one and others developed by Kaiser. The fol-
must appreciate is how complex the practice lowing topics will be covered:
of medicine has become. For a frontline prac- • The relationship of medication errors to
titioner, there are always new medications, unsafe acts
new technologies, new procedures, and new • The role of understanding human factors in
research findings to assimilate. Patients too addressing unsafe acts
are becoming increasingly complex, and the • Establishing a safe and just culture for error
diversity of the health care workforce grows reporting
at an increasing rate. Providing safe, reliable • The importance of education and training to
care has never been more challenging. support medication safety programs
• The use of new technologies in medication
This chapter will present the experiences and safety programs
approaches of teams at Kaiser Permanente in • The use of independent double checks as a
addressing the challenges of reducing medi- final safeguard against medication errors
cation errors and how improvements in medi- • Engaging the patient in medication safety
cation safety can be realized through changes through nurse interaction processes and
in systems and improvements in communica- health literacy
tion and teamwork. Such changes can benefit • Safeguarding medication administra-
nurses and nurse leaders by providing guid- tion time and reducing distraction through
ance for improving system reliability and fos- signaling
tering a culture that moves beyond naming,
© 2012 Kaiser Permanente, Chapter 1 5

• Measuring and monitoring the effective- medication errors that cause harm to Kaiser’s
ness of a medication safety program and patients, KPNC implemented the High-Alert
the continual quest for improvement Medication Program (HAMP) in December
2005 (see Sidebar 1-1 on page 7).
Background of the Development
HAMP was implemented in 21 KPNC medical
of Kaiser’s Medication Programs centers. Making and sustaining a change of
Although many medication errors do not cause this magnitude can be extremely difficult. The
grave harm to patients, some medications are culture at Kaiser was one that promoted indi-
known to carry a higher risk of harm when vidual facility innovation and a focus on results;
given in error than other medications, and rarely was a specific process approach man-
errors in the administration of these medica- dated at the regional level. Given the serious-
tions can have catastrophic clinical outcomes. ness of the ADEs that led to the development
These medications are identified as high-alert of HAMP, however, there was recognition of
medications and require special attention. the importance of consistency across facilities
One of the National Quality Forum’s “Safe in the medication safety–related processes,
Practices for Better Healthcare” is to “identify in order to meet the goals. The approach to
all high-alert drugs, and establish policies and successful implementation included several
processes to minimize the risks associated key areas (see Figure 1-1 on page 8). What
Relevant Requirements with the use of these drugs.”2(p.viii) follows describes how HAMP was not only
Joint Commission Medication sustained but was continually improved and
Management (MM) Standard A More Focused Approach how similar medication safety programs and
MM.01.01.03 states, “The
Chemotherapy drugs are among the many activities were developed throughout the
organization safely manages
high-alert medications. Kaiser system.
high-alert and hazardous
medications.”
In July 2005, a 21-year-old patient was admit- Medication Errors and Unsafe Acts
ted to the hospital for treatment of lymphoma.
This patient began receiving chemotherapy Sadly, most preventable harm to patients
and was responding well to treatment. On receiving health care today is caused by the
August 26, 2005, the patient received a medi- unsafe acts of the very practitioners who are
cation intended for another patient. Worse still, trying to help them. Unsafe acts may be cat-
almost immediately the physician recognized egorized as either human errors or procedural
that the agent that had been injected into the violations. Human errors may be further cat-
patient’s intrathecal (spinal) catheter was vin- egorized as slips, lapses, and mistakes—all
cristine, a chemotherapy medication that is inadvertent acts. Procedural violations include
lethal when administered into the spine. Three at-risk or reckless behavior, which are inten-
High-Alert Medications days later, this 21-year-old died from the con- tional acts. The experience at Kaiser Perma-
Resources sequences of the medication error. nente is that most medication errors are not
The Institute for Safe Medica- caused by human error alone nor by willful vio-
tion Practices publishes a More than 500,000 doses of high-alert medi- lations of intelligible, available, workable, and
high-alert medication list on its cations, such as vincristine, are administered correct procedures to the point of gross reck-
Web site at www.ismp.org/tools/
throughout KPNC on an annual basis. Fol- lessness. Rather, medication errors usually
highalertmedications.pdf. The list
lowing three major ADEs at Kaiser, including happen by some combination of human error
presents drugs in 19 categories.
the one described above, KPNC leadership and drift from procedure—situations in which a
determined that a more focused approach for health care provider was doing what seemed
high-alert medications was needed. To ensure logical to him or her at the time to complete a
safe medication practices and to eliminate task for the patient.
6
CHAPTER ONE: Medication Safety: Reducing Error Through Improvement Programs
Responses to Unsafe Acts

One response to human fallibility involved Unsafe Acts
in unsafe acts (whether errors or violations) Sadly, most preventable • Human errors: slips, lapses,
and to preventing those acts from reaching harm to patients and mistakes
patients is to focus exclusively on the perpe- receiving health care • Procedural violations: at-risk
trators, blaming them for forgetfulness, inat- today is caused by the or reckless behavior
tention, needless risk-taking, and even moral unsafe acts of the very
weakness. A second response is to focus practitioners who are
more on the conditions under which individu- trying to help them.
als and teams work. Under the second model,
work flow and defenses are designed to avert
errors, the conditions that lend themselves to
violations are minimized, and mechanisms are Given professional cultures grounded in auton-
put in place to mitigate unsafe acts that may omy and individual culpability—cultures that
nevertheless occur. have historically equated unsafe acts with
SIDEBAR 1-1. Kaiser Permanete Nothern California High-Alert Medication Program

(HAMP)
HAMP Objectives the limited list of high-alert medications, processes,

The overall purpose of the High-Alert Medication and patient types that would be part of the high-alert
Program (HAMP) developed by Kaiser Permanete medication program for KPNC. The steps included
Northern California (KPNC) was to ensure safe med- the following, which were described in detail in the
ication practices and to eliminate medication errors first edition of this book:
that cause harm to patients. These goals were to be Step 1: Development of the High-Alert
achieved by doing the following: Medication List
• Standardizing medication handling practices Step 2: Establishment of the Scope of the Program
• Enhancing education programs related to Step 3: Policies and Procedures
medication practices, embedding these into Step 4: Communication
annual core competencies of all staff who handle Step 5: Education
medications Step 6: Monitoring
• Developing monitoring functions at both the
regional and local levels to ensure sustainability Measurement
and ongoing systems improvements For step 6, an Audit Subgroup of the Regional
Medication Safety Committee was established to
HAMP Methodology design monitoring tools and procedures to ensure
In November 2005 the KPNC Regional Medication complete implementation, staff competency, and
Safety Committee chartered the High-Risk Medica- consistent application of the requirements of the
tion Safety Task Force for the purpose of drafting a program. Regionally, reporting was to be ongoing,
proposal for standardizing the handling of high-alert using the Regional Quality and Risk database to
medications throughout KPNC. This core multidis- track the trends in high-alert medications involved
ciplinary group, including Kaiser Foundation Health in adverse events. As HAMP has matured, the
Plan/Hospital & The Permanente Medical Group measurement strategy, described in the first
leaders, managers, and frontline staff and physi- edition of this book, has evolved.
cians, was brought together for a full-day, intensive
decision-making event to establish a plan, determine Source: Kaiser Permanente. Used with
the working groups, define the scope, and establish permission.
7
FIGURE 1-1. Tools and Strategies for Minimizing Errors in High-Alert

Medication Administration
• Standardize Protocols: This is vital for administering high-alert drugs.

• Communicate with SBAR: SBAR is a standardized tool for succinctly communicating with another health care
provider about a situation that requires urgent attention. SBAR stands for the following:
◦ Situation—What is going on with the patient?
◦ Background—What is the clinical background or context?
◦ Assessment—What do I think the problem is?
◦ Recommendation—What would I suggest to correct it?
• Use Critical Language: Using standardized critical language provides all clinicians with tools for appropriately
asserting concern in a clinical setting that may be hierarchical. Examples of a common critical language
include the following statements: “I’m concerned,” “This doesn’t feel safe,” “I’m worried,” or “I just need a little
clarity.”
• Encourage Responsible Reporting: To continually address potential problems in administering medication,
data and shared information regarding near misses and actual errors are essential (see “Effects of Disruptive
Behavior/Incivility on Medication Safety” and “Error Reporting in a Just Culture” on pages 13–14).
• Conduct Small Tests of Change: Create a structured format for suggesting improvements, developing a
project that is small in scope, testing it, learning from it, making appropriate modifications, then encouraging
its spread throughout the medical center.
• Use Independent Double Checks: A check of the “five rights” (including time of administration and intravenous
(IV) settings, calculations, and infusion rates, if applicable) is performed independently by a second qualified
health care practitioner (see “Independent Double Checks” on pages 21–22).
• Improve Handoff Communication: An independent double check is required whenever a transfer of responsi-
bility for the care of the patient occurs.
• Assess the Physical Space: Using small tests of change and communication with leadership, make sugges-
tions to improve the physical space and work environment, particularly by mitigating interruptions and distrac-
tions.
• Use the Universal Protocol for Time-Out: Immediately before starting an administration/procedure, a time-out
must be conducted at the actual location where the procedure will be done or the medication administered. It
must involve the entire care/procedure team, use active communication, and be documented.
• Apply Ongoing Education: Monitor compliance and comprehension of policies and procedures with short sur-
veys; supervisors must also provide one-on-one training, feedback, and reminders in a psychologically safe
environment. It is critically important that people feel safe speaking up. Psychological safety has a profound
impact on team performance (see “Patient Safety Education/Training” on pages 15–19).
◦ Does it feel safe to speak up?
◦ Will I be treated with respect?
◦ Will they help fix my problem?
• Provide Staff with Updates About Policies and Procedures: Educate staff thoroughly about new technologies
and medical devices; educate staff to heighten awareness of human factors issues (see “Human Factors and
Medication Safety” on pages 9–13).
Source: Kaiser Permanente. Used with permission.
8
incompetence, it is (perhaps) predictable that 2. Many errors are caused by activities that
the dominant response in health care after rely on weak aspects of cognition.
adverse outcomes has been to turn attention 3. Systems failures are the “root causes” of
to the individuals at the “sharp end” of care— most errors.
the physicians, nurses, pharmacists, and other
professionals providing care every day. Coun- Framed another way:
termeasures are directed mainly at reducing 1. Most patient injuries are preventable.
unwanted variability in worker behavior. These 2. The primary causes of preventable injuries
methods include poster campaigns that appeal are not bad people but bad systems.
to people’s sense of fear, writing more proce- 3. To prevent injury there is often a need to
dures (or modifying existing ones), disciplinary redesign systems.
measures, threats of litigation, retraining (usu-
ally involving outdated and ineffective training Thus, unsafe acts may be viewed as conse-
methods), and naming, blaming, and shaming. quences of flawed medication safety programs
rather than causes of preventable medication
Focusing on the individual origins of errors and errors, originating not so much from human
violations isolates unsafe acts from their sys- failing as from “upstream” systemic factors. As
tem context. As a result, the pursuit of greater such, countermeasures can be built based on
safety is seriously impeded by an approach the assumption that although the human con-
that does not seek out and remove the error-/ dition cannot be changed, there can be both
violation-provoking properties within the sys- an accommodation of the human condition as
tem at large. Though some unsafe acts in well as a change in the conditions under which
medicine are truly reckless or egregious, and humans work. With this point of view in mind,
must be dealt with severely, the vast majority it is possible to shift the focus to identifying
are not. systemic factors or conditions that may cause
unsafe acts.
Defined: Human Factors and

Human Factors and Medication Human Factors Engineering
Focusing on the
individual origins of
Safety Human factors is a field of study
that focuses on humans and
errors and violations One of the key elements of the Kaiser medi- their interactions with each other,
isolates unsafe acts cation safety program that has supported products, equipment, proce-
from their system many of the changes and the ability to sustain dures, and the environment. It
context. and improve over time relates to addressing leverages what we know about
human factors. So what is known about human human behavior, abilities, limita-
tions, and other characteristics
factors that is relevant to medication safety in
to ensure safer, more reliable
terms of human behavior, abilities, limitations, outcomes. Human factors engi-
Causes of Unsafe Acts and other characteristics? How could/does neering applies the understand-
The good news is that the causes of unsafe this knowledge help us reduce unsafe acts— ing of human capability (human
acts in health care are largely known. With an human error and procedural violations? factors science) to the design,
understanding of causation, systemic solu- development, and deployment of
tions can be implemented to improve per- Violation-Producing Conditions systems and services.
formance. We can start from the following With respect to procedural violations by a
position in Lucian Leape’s landmark article practitioner who might drift from safe practice,
“Error in Medicine”3: Jeremy Williams, a British ergonomist with
Errors are common: experience in many hazardous technologies,
1. The causes of errors are known. has identified a number of “violation-producing
9
conditions” that influence a person’s likelihood ◦ Environmental factors such as noise,

of failing to comply with safe operating prac- lighting, temperature, interruptions and
tices.4 These include the following: distractions, clutter, and available space
• Perceived low likelihood of detection ◦ External constraints (for example, regu-
• Inconvenience involved in following safe latory) that affect one’s ability to perform
methods as expected
• Apparent authority or status to violate ◦ Whether or not there is a mechanism in
• Copying behavior place to identify and trap errors before
• No disapproving authority present they have a chance to cause serious
• Group pressure problems
• Endogenous factors: Endogenous factors
Exogenous and Endogenous Factors are those that are generated within one’s
With respect to human error, even those who own human system. They may be psycho-
are fully intent on being 100% compliant with logical, physiological, or both. Examples
safe practices, 100% of the time, fail fre- include the following:
quently—and to the point Leape would make, ◦ Sleep deprivation—It has been shown
the causes are known. There are primarily two that cognitive performance after 24
types of human factors issues that increase a hours without sleep is equivalent to
person’s propensity to human error: They are performing with a blood alcohol level of
exogenous factors and endogenous factors. 0.10.5
◦ Stress—Current research seems to indi-
• Exogenous factors: Exogenous factors are cate that stress may have its biggest
those that originate outside of one’s own negative effect on knowledge-based
body and include such elements as the workers (workers who are valued for
following: their ability to employ a body of knowl-
◦ The design of the task or the work flow edge in a specific subject area), for
itself (Is it easy to do the right thing and example, health care workers. Stress
hard to do the wrong thing?) is also a likely contributor toward tunnel
◦ The type and amount of training provided vision, a mode of thinking in which one
(Is there a good match between the skill gets lost in the details and loses sight of
or knowledge level of the worker and the the bigger picture.
demands of the job?) ◦ Fatigue—The result of physical, mental,
◦ The resources that are available to get or emotional exertion, fatigue is a condi-
the job done tion of weariness or exhaustion that
◦ The time provided to get the job done (Is can severely affect one’s physical and/
there a good match between the work- or mental capabilities, including the
er’s capacity to get the job done and the ability to make sound decisions. Some
amount of work to be done?) research suggests that nurses who work
◦ The worker’s familiarity with relevant shifts of 12.5 hours or greater are three
policies and procedures times more likely to make an error than
◦ The communications and information their colleagues working shorter shifts.6
environment (How clearly and frequently ◦ Anger—In health care, anger is often
are important pieces of information on generated by a host of exogenous
getting the job done correctly delivered factors (for example, issues with
to the worker?) information flow, equipment/material
conditions or readiness, lack of clear
roles and responsibilities, staff compe-
10
tency issues), but it manifests itself the patient’s armband, and other factors may
endogenously and is not good for the all affect the nurse’s ability to accurately per-
worker, his or her colleagues, or—most form the five rights of medication administra-
importantly—the patient’s safety.7 tion at the bedside. Depending on the route of
administration, there may be additional skills
required, and if the drug to be administered
Human Factors in Task Analysis is a high-alert medication requiring indepen-
Any particular task or set of tasks workers per- dent double checks, more team dynamics may
form may require them to interact with each come into play.
other, products, equipment, procedures, and
the environment; therefore, such tasks may be Mitigation and Elimination Strategies
examined from a human factors perspective. Drawing on an understanding of the conditions
It is helpful when examining medication man- that contribute to unsafe acts, an organization
agement from a human factors perspective can redesign, develop, and deploy medica-
to look at it from an end-to-end perspective, tion processes and systems to keep both the
analyzing each of its core components (that is, patient and the worker safe. Specific strate-
prescribing, dispensing, administering, moni- gies that demonstrate knowledge and appli-
toring), in terms of the following: cation of human factors principles include the
• Physical demands following:
• Skill demands • Simplify the structure of tasks to help
• Mental work load minimize the load on vulnerable cognitive
• Team dynamics processes such as working memory.
• Environmental conditions • Standardize work flows, equipment, and
materials to better assess outcomes, train
An end-to-end example. For example, in new staff, and improve ease of use.
the medication administration phase, from • Avoid reliance on memory and vigilance to
the time a nurse receives an order to admin- minimize the risk of slips and lapses.
ister a medication on a hospital floor to the • Improve access to information to improve
time the medication is administered there are decision making and efficiencies and to
multiple steps and demands on him or her. reduce reliance on memory.
The nurse may have to access an automated • Promote effective team functioning through
medication dispensing machine and ensure enhanced training strategies (for example,
that what is in the electronic health record is simulation) and development of commu-
what is being pulled from the dispenser. The nication skills to better leverage existing
nurse is expected to make purposeful deci- resources, minimize errors, and recover
sions and judgments to ensure that the medi- from harm when it does occur.
cation he or she pulls is the right medication, • Provide intelligent decision support, such as
for the right patient, via the right route, at the smart intravenous (IV) pumps and clinical
right dose and time. Proceeding to the patient’s practice alerts, to aid practitioner decision
room, the nurse may be interrupted by a team- making under conditions of uncertainty.
mate or another patient needing help. While • Take advantage of habits and patterns to
in the room, the nurse needs to communicate make it easy to do the right thing.
with the patient and include the patient in the • Apply the power of constraints and forcing
medication administration process. Environ- functions to make it hard to do the wrong
mental conditions, such as lighting and noise thing. (For more on forcing functions, see
distractions, may contribute. The mental work page 88 in Chapter 4.)
load, the patient’s literacy level, the quality of
11
• Deploy redundancies, where appropriate, process that can be particularly helpful when a
to capture and mitigate an error before it new product or device is being considered or
has the chance to do harm. introduced into the work flow. From a human
• Use visual controls, such as signage (post- factors perspective, the organization might
ers, labels), to shape desired behavior. focus on the following:
• Clarify roles and responsibilities regarding • Is the user given prompts and salient feed-
both routine and infrequent tasks so that back after each action?
everyone is absolutely clear about who is • Are the functions of the various controls
accountable for what. clear and obvious?
• Increase risk resilience through regular and • Are the displayed messages easy to
supportive feedback to frontline practitio- understand?
ners about the adverse outcomes and close • What is the load on the user’s memory?
calls that their colleagues are experiencing. Some studies have indicated that five to
• Create systems that are better able to seven chunks of information is about the
tolerate the occurrence of unsafe acts and most we can reliably store at any one time.
contain the consequent damaging effects • Are there clearly marked exits for users to
when they do occur. This includes making leave the system or function or to cancel an
the actions (and outcomes) of practitioners action?
more visible and using substitution and • Does the existing knowledge or training of
other mitigating strategies to lessen the the users make it more difficult to learn how
impact of unsafe acts. to use the system properly?
• Foster a climate of psychological safety in • Are there multiple types of users or groups
which everyone is encouraged to speak who will use the machine differently
up when they observe deviations from depending on their roles?
accepted practices or see conditions or • Are there problems associated with the
circumstances that require a change of user taking back control when something
approach—a climate in which respect is goes wrong with automation (switching
Defined: Usability Testing
afforded to each member of the team (see from autopilot to manual)?
Usability testing is a form of task
analysis in which the use of a “Effects of Disruptive Behavior/Incivility on • Does the system use symbols, alarms,
device or system is observed in Medication Safety” and “Error Reporting in or controls that appear similar to other
several stages, including a real- a Just Culture” on pages 13–15). currently used machines but that function
use simulation. User feedback on • Eliminate environmental factors that differently?
the process steps are recorded degrade performance, such as clutter, • Does the system create unexpected tasks
and analyzed to determine flaws inadequate lighting, excessive noise, and or procedures (that is, workarounds) that
or errors with the procedures,
needless interruptions and distractions. need to be performed in conjunction with
instructions, training, or design of
• Use clear, unambiguous labeling, including the operation of the system?
the device or system.
color coding where helpful and avoidance • How does the system affect the way current
of look-alike/sound-alike medications. activities are carried out? Does it hinder
other activities?
Usability Testing • What environmental conditions (for exam-
In addition to the previous strategies, an ple, noise, light levels) make using the
organization may decide to conduct a form of system difficult or impossible?
task analysis known as “usability testing,” a
12
In summary, identifying and mitigating human and employees in establishing a culture that
factors that can result in medication errors is ensures psychological safety. This initia-
critical to enhancing patient safety. An effective tive included creation of a policy that clearly
system must both address biases and cultural defines inappropriate and disruptive behavior.
paradigms as well as implement safeguards The policy ensures that reports of disruptive
and backup systems. Medication safety is a behavior are investigated and responded to
result of day-to-day practices and behaviors, in a fair and consistent manner and that they
including a commitment to patient safety and are tracked to evaluate and monitor trends in
the humility to stay vigilant. professional conduct. For staff and contracted
physicians and surgeons, this information is
Effects of Disruptive Behavior/ included in the regular Ongoing Professional
Practice Evaluation reporting process and in
Incivility on Medication Safety
biannual reappointment reviews. Education
One behavior that organizations must address for staff—including physicians and manag-
is disruptive behavior/incivility. The Joint Com- ers—was also needed to enhance their skills
mission Sentinel Event Alert 40, “Behaviors in discussing uncomfortable issues. Policies
That Undermine a Culture of Safety,” issued on can provide a framework for better relations
July 9, 2008, highlights the strong relationship between workers, but health care profes-
between a safe culture and disruptive behav- sionals need to practice these techniques to
ior. On effective teams, every member must be ensure both comfort and competence.
able to ask questions if they lack understand-
ing and issue warnings if they perceive unsafe How a Culture of Safety Supports Nurses
acts. In addition, members of effective teams A culture of safety supports nurses in manag-
are constantly challenging each other to drive ing patient medications. In safe environments,
for higher performance. Team dynamics are nurses confidently ask questions and discuss
extremely important for meeting the demands concerns with the multidisciplinary team in
of safe medication management. an environment of respect, comfortably draw
on the systems that have been designed to
Hospital leaders must ensure that everyone in ensure medication safety, and communicate
the organization recognizes the devastating in a constructive manner with anyone who
effects of inappropriate and disruptive behav- attempts to encourage them to cut corners.
ior. Such behavior can be overt (for example,
yelling, using profanity, engaging in physical The education process at these two medical
violence) or covert (for example, ignoring centers includes the following:
attempts at conversation, eye rolling, sarcac- • Initial education for all physicians and staff
stic or patronizing voice intonation). Although on disruptive behavior
much attention has been paid to disruptive • Horizontal hostility training for all new
behavior by physicians, all levels of staff can nurses
have communication issues that need to be • Disruptive behavior and incivility training for
addressed. Incivility can also arise during all new hires
group-to-group interactions in which medical • Definition of incivility and setting a stan-
staff are not involved. dard for civil behavior throughout the
organization
Creating a Policy to Support a Safe Culture • Crucial conversation training for leaders,
Two Kaiser Permanente medical centers chiefs, directors, and managers
have created an infrastructure that clearly • Forgiveness classes, as appropriate
defines the responsibilities of all physicians • Anger management classes, as appropriate
13
At both facilities there has been a commitment Training in the use of the algorithm often
by leadership to address behavior issues involves using scenarios like the following:
early on and rapidly. It seems to have made
a difference already. In addition, leadership at A new graduate R.N. was assigned to the medical/
one of the medical centers has signed a Civil- surgical unit prior to orientation and skills evalua-
ity Pledge that will be posted on the facility’s tion. She was assigned a full patient load. A senior
intranet. This work is now being spread to R.N. was assigned to precept the new graduate. The
other Kaiser medical centers. senior R.N. also had a full caseload of patients, all
requiring high-intensity care. Because of the senior
Error Reporting in a Just Culture R.N.’s caseload, she was able to give only limited
supervision to the new R.N. During the first week
Providing a safe culture that supports error the new grad made a medication error that she
reporting and treats staff fairly when an error reported to the senior R.N. During the second week
occurs is an ongoing process. In addition to the she made a similar error that was not noted until
safety culture policy and training described pre- the next shift when a count of the controlled medica-
viously, many organizations, including Kaiser, tions was not correct. In reviewing the chart, neither
are applying the tenets of a just culture. the new grad’s documentation nor the medication
administration record (MAR) had been cosigned by
So what is a just culture? According to a posi- the senior R.N. The new grad had not entered the
tion statement on the topic recently adopted medication administration onto the MAR, and this
by the American Nursing Association, “a Just had not been “caught” by the senior R.N.
Culture recognizes that individual practitio-
ners should not be held accountable for sys- The training group is then taken through the
tem failings over which they have no control. algorithm, and the group members are asked
A Just Culture also recognizes many indi- to use it to determine how they would handle
vidual or ‘active’ errors represent predictable the situation. The key questions reviewed are,
interactions between human operators and Were the actions as intended? Was substance
the systems in which they work. However, in abuse involved? Were safe operating proce-
contrast to a culture that touts ‘no blame’ as dures knowingly violated? Did the incident
its governing principle, a Just Culture does not pass the substitution test? and, Was there
tolerate conscious disregard of clear risks to a history of unsafe acts? Depending on the
patients or gross misconduct (e.g., falsifying facts and the responses to these questions,
a record, performing professional duties while the algorithm flowchart will lead the group to a
intoxicated).”8(pp. 2–3) This policy statement also recommended action.
supports the use of a just culture algorithm.
Updating the algorithm. The managing error
Just Culture Algorithm algorithm is continually updated based on con-
Kaiser’s just culture policy, “Managing Error cepts gleaned from the literature (particularly
in a Just Culture,” has been revised to require the work of David Marx, James Reason, and
the application of the organization’s just culture the Institute for Healthcare Improvement) as
algorithm in decisions regarding disciplinary well as on Kaiser’s own experience.
action for individuals who err (see Figure 1-2 on
pages 16–17). In the past the policy suggested
the use of the algorithm but did not require it.
14
Establishing a just culture advisory board. Patient Safety Education/Training

To support leaders and managers in their use
of the algorithm, Kaiser established a Regional Policies and procedures alone cannot ade-
Just Culture Advisory Board. The advisory quately address unsafe acts. At Kaiser, sev-
board provides case review, consultation, eral other processes and education programs
and recommendations to medical center lead- have been put in place to hardwire error
ers and managers related to decision making reporting and a safe, just culture into the orga-
about appropriate handling of individual cases nization. Based on an understanding gained
of employees who make errors that could or from the study of human factors, Kaiser real-
did lead to patient harm. In addition to pro- ized that it is important to provide health care
viding expert consultation and recommenda- workers with the knowledge, tools, and train-
tions, the advisory board identifies and makes ing necessary to mitigate and eliminate medi-
recommendations to decrease variation in cation errors. In this way, an organization is
the medical center decision-making process, able to implement and sustain a program to
shares best practices, shares lessons from support the safest care possible for patients.
errors and the handling of errors, and makes
recommendations for improvements in clinical Patient Safety University
or administrative systems. In the past at Kaiser Permanente, the usual
approach had been to provide ad hoc patient
An automated algorithm. Another support safety education/training for teams at the
tool—currently in the pilot phase—is an auto-
mated version of the just culture algorithm that
shared in Figure 1-2. The algorithm is based
Policies and procedures
on the work of the National Patient Safety
alone cannot
Agency, which is a special health authority of
adequately address
the British National Health Service. This Web-
unsafe acts.
based tool provides decision support as the
leader/manager progresses through the algo-
rithm. The automated decision tree is simple
to use and does not require special computer regional level or for teams at individual medi-
skills. This tool does not replace the current cal centers. This was usually presented as
paper process but provides alternative aimed part of a patient safety program or initiative on
at ensuring that the algorithm is used. specific topics such as human factors, just cul-
ture, reliable design, and communication and
In addition to the automation of the algorithm, teamwork. Although this type of education/
Kaiser’s Responsible Reporting Form (on training is important and is still provided as
which providers report “unusual events”) is needed, leadership at Kaiser determined that
now electronic. The paper version, which was a more systematic approach that reached all
described in the previous edition of this book, levels of the organization was vital. To that end
was automated in response to input from staff the Patient Safety University (PSU) was devel-
and managers regarding the length of time oped. The overall aim of the PSU—creating
that it took them to fill out the paper tool. the safest care system for Kaiser’s patients—
relies on a three-pronged approach:
15
FIGURE 1-2. Managing Error in a Just Culture—An Algorithm for Promoting a

Culture of Patient Safety
1.0 Policy Statement

Kaiser Permanente Leadership and Management are responsible for creating and sustaining a just culture. KFH
[Kaiser Foundation Hospital] leaders and managers are required to use the algorithm in Section 5.0 when making
determinations on whether or not to discipline individual(s) who err. If any provision of this policy conflicts with
a collective bargaining agreement, enforceable standard or regulation, the collective bargaining agreement,
standard or regulation supersedes.
2.0 Scope
This policy applies to all employees in the Northern California Region working in any of the following entities (col-
lectively referred to as “Kaiser Permanente”):
2.1 Kaiser Foundation Health Plan, Inc., and Kaiser Foundation Hospitals (together, KFHP/H)
2.2 KFHP/H’s subsidiaries
3.0 Responsibility
All staff are responsible and encouraged to report errors and near misses to management. When an error or near
miss occurs, senior leadership and middle management are responsible for using the process described in 5.0
to encourage and sustain a just culture. Should there be disagreement regarding discipline, the ultimate decision
regarding disciplinary actions rests with the Area Manager.
4.0 Definitions
4.1 Human Error: Inadvertent or unintentional action that causes or could have caused an undesirable out-
come; also referred to as a slip or a lapse.
4.2 At-Risk Behavior: Behavior that increases risk where risk is not recognized or is mistakenly believed to be
justified.
4.3 Reckless Behavior: Behavioral choice to consciously disregard a substantial and unjustifiable risk.
4.4 “Just Culture”: A culture in which people are encouraged, even rewarded, for providing essential safety-
related information. In a “just culture” clear information is provided about where the line must be drawn
between acceptable and unacceptable behavior. A “just culture”
• Recognizes that human beings make mistakes
• Supports reporting
• Doesn’t advocate blame, shame, and train
• Advocates fair treatment
• Has intolerance for reckless behavior
• Is based on trust
4.5 Substitution Test: Also known as the “reasonable person test,” this test asks the question “Would another
individual coming from the same professional group, possessing comparable qualifications and experience,
behave in the same way in similar circumstances?”
4.6 System: The Institute of Medicine (IOM) defines a system as a “set of interdependent elements interacting
to achieve a common aim.” These elements may be both human (communication, teamwork), and non-
human (work environment, equipment, technologies, policies and procedures, delivery systems, etc.) The
IOM goes on to say that “Safety does not reside in a person, device, or department, but emerges from the
interactions of components of the system.”
4.7 Violations/Drifting: In general, a violation is a decision on the part of an individual to bend rules (when
noncompliance has become the “normal” way of working, we call this drift or normalization of deviance).
Drift or normalization of deviance is when a group of individuals (e.g., hospital unit) “drift” into unsafe habits
and lose perception of the risk attached to these behaviors. An example of “drift” is routine short cuts that
have become the norm for a unit. In some cases, these short cuts are inadvertently rewarded for saving
16
FIGURE 1-2. Managing Error in a Just Culture—An Algorithm for Promoting a

Culture of Patient Safety (continued)
time or money. The problem is that the “drift” becomes so common that perception of the risk fades or is
believed to be justified—until there is a catastrophic event.
5.0 Procedure
Leaders and managers are required to use the procedure outlined in the just culture algorithm when making
determinations on whether or not to discipline individual(s) who err. Also refer to the applicable collective
bargaining agreements for appropriate disciplinary/corrective action.
1. Building a culture of safety for the care This Web-based program is designed for all
team and environment staff who are directly or indirectly involved in
2. Building skills in teamwork and patient care, including physicians and nurses,
communication as well as front desk, lab, and pharmacy staf-
3. Ensuring a consistently delivered, fand those in many other roles. The course,
evidence-based design for daily work launched during the 2011 Patient Safety
Awareness Week, can be taken by individuals
PSU1. The first phase (PSU1) is a two-day or by groups in a classroom setting. A typical
program that targets senior leaders, manag- curriculum is shown in Figure 1-4 on page 19.
ers, service line directors, and physician chiefs.
The program is designed to help leaders under- Education/training is essential in providing the
stand what their top safety issues are and build knowledge base necessary to implement a suc-
their own plans for making change happen cessful medication safety program, but there
within their medical center. A typical agenda for is no guarantee that the knowledge and skills
the two days is shown in Figure 1-3 on page 18. training provided will be implemented. Other
elements, including technology, are necessary
PSU2. The second phase of the PSU (PSU2) to support the implementation of processes
came about in response to requests from lead- and the sustaining of these processes over
ers and managers for an education/training pro- time. Web-based education/training and auto-
gram for direct care staff and physicians, similar mated just culture algorithms are just a few
to that in PSU1. The aim of PSU2 is to offer examples of how interactions and knowledge-
direct care providers a foundational background sharing among health care workers can ben-
and skills that lend themselves to applying the efit from technology. In addition to these, other
three-pronged approach described above into specialized technologies have been critical to
their daily practice. the success of medication safety programs.
PSU2 begins with an introduction to safety The Role of Technology in a

principles and concepts, and then builds on
Medication Safety Program
them to help participants learn and employ
specific practical applications to develop, The use of newer technologies has been credited
implement, and sustain a culture of patient with reducing medication errors in the various
safety at the department/unit level. phases of medication use. These technolo-
gies include computerized provider order entry
17
FIGURE 1-3. Patient Safety University—Phase 1: Agenda
Phase 1: Agenda
Patient Safety University

[Enter Name of Facility]
[Enter Dates of PSU]
[Enter Address and Location of PSU]
Date/ Time Topic

Day 1
7:30 – 8:00 A.M. Registration and Breakfast
8:00 – 8:15 A.M. Welcome and Purpose
8:15 – 8:30 A.M. Introductions and Course Overview
8:30 – 10:00 A.M. Introduction to Patient Safety: Human Factors, Systems Conditions, and Medical Errors;
Workplace Safety and Service
10:00 – 11:00 A.M. Creating a Culture of Safety
11:00 – 11:10 A.M. Break
11:10 A.M. – 12:40 P.M. Responsible Reporting and Accountability in a Just Culture
12:40 – 1:10 P.M. Lunch
1:10 – 2:10 P.M. Proactive Hazard Identification
2:10 – 2:20 P.M. Break
2:20 – 4:10 P.M. Incident Analysis and Error-Proofing Strategies
4:10 – 4:50 P.M. Dialogue regarding where [enter name of medical center] is in area of human factors and
“just culture”
Discussion of leadership vision of the future and their thoughts on promulgating a “just
culture,” etc.
4:50 – 5:00 P.M. Wrap-up
Day 2
7:30 – 8:00 A.M. Breakfast
8:00 – 8:15 A.M. Review Day 1 and Plan for Day 2
8:15 – 9:45 A.M. Teamwork and Communications: SBAR, Teach-Backs, Briefings, Assertion, Escalation
9:45 – 10:00 A.M. Break
10:00 – 11:00 A.M. Observation and Coaching
11:00 A.M. – 12 P.M. Health Literacy
12:00 – 1:00 P.M. Lunch
1:00 – 2:30 P.M. Reliable Design
2:30 – 2:40 P.M. Break
2:40 – 3:40 P.M. Application of Reliability Principles
3:40 – 3:55 P.M. Connecting the Dots
3:55 – 4:25 P.M. Closing Remarks and Vision of the Future Expectations
18
FIGURE 1-4. Patient Safety University—Phase 2: Course Content
Phase 2: Course Content
Patient Safety University

[Enter Name of Facility]
[Enter Dates of PSU]
[Enter Address and Location of PSU]
Module Time Frame

Introduction to Patient Safety—Human Factors, Systems Conditions, and Medical Errors 1 Hour
This module sets the stage for the following three modules by introducing key patient safety terms,
concepts, and principles. The module describes the scope of the problem of errors in health care
and identifies common causes of human errors and procedural violations in health care and what
we need to do differently.
A Safe and Just Culture 1 Hour
This module begins with a definition of a culture of safety and discusses why Kaiser’s current
culture needs to change. Discussion then moves on to the importance of error reporting and learn-
ing from the organization’s errors. A major focus of the module is the interactive workaround, the
concept of a “just culture,” and the behaviors associated with adverse outcomes. The module ends
with a discussion of “drift” and actions that can be taken to identify and act on “drift.”
Communication and Teamwork 1 Hour
Communication and teamwork are the focus of module 3 and begins with a description of the
importance of the health care team in ensuring safe, reliable patient care. The components of
high-performing health care teams and key concepts of teamwork are discussed, and group work
is done around tools for teamwork.
Lead from Where You Stand—Your role in improving patient safety at Kaiser Permanente 1 Hour
This module pulls all of the previous modules together and includes discussions on safe practices
relevant to specific work areas, enhancing communication and teamwork, addressing drift, and
error reporting. Group activities include role playing on observing and providing feedback to team
members, and aligning patient safety projects with performance improvement work.
(CPOE) in ordering and transcribing; robotics in one Kaiser Permanente Medical Center
and automated drug dispensing devices in dis- in 2006 and have since been successfully
pensing; and electronic medication administra- deployed in 21 medical centers across Kai-
tion records (eMARs) and bar code medication ser’s Northern California region.
administration (BCMA) systems in drug adminis-
tration.9–11 (For more on integration of technology Following the implementation of CPOE and
in medication safety programs, see Chapter 2.) BCMA, the pilot facility experienced a significant
improvement in the five rights of medication
Improvements Resulting from CPOE administration (right patient, right medication,
and BCMA right dose, right time, right route), resulting in a
CPOE and BCMA were first implemented 57% overall reduction in medication errors.
19
Implementation of CPOE and BCMA at other ery model before the selection process is
Kaiser Permanente facilities has yielded simi- implemented.
lar results. Significant reductions in errors of • Applied Engineering: Human factors design
dispensing and administration at one of Kai- and cognitive systems engineering must be
ser’s facilities were attributed to the increased applied to ensure optimal utilization.
use of standardized drug products resulting • A Focus on Phases: Careful attention to
from the adoption of CPOE standardized order each phase of the bar coding process will
sets. The facility also reported a significant lead to the proper use of systems and
reduction in drug administration errors due decrease the probability of workarounds.
to BCMA and the use of independent double
checks at the patient’s bedside prior to the Identifying and Addressing BCMA
administration of high-alert medications. (Also Workarounds
see “Independent Double Checks” on page The goal of highly reliable BCMA systems is
21.) to identify challenges to nursing work flows,
identify best practices for improving medi-
Careful Planning in the Use of CPOE cation safety, and apply lessons learned to
and BCMA ensure sustainability. The failure to under-
Although CPOE and BCMA systems have stand existing work flows and the impact of
The Joint Commission many benefits and can improve medication changes resulting from the introduction of new
Sentinel Event Alert 42 safety, they are complex and can be difficult technologies may promote workarounds that
The Joint Commission Sentinel to implement and expensive to purchase bypass the safety features designed into these
Event Alert 42, “Safely
and maintain. Selection and implementation systems.
Implementing Health Information
of health care technology systems, such as
and Converging Technologies,”
also provides a set of guidelines CPOE and BCMA, require careful planning, In one study of BCMA workarounds, the
for adopting technologies in and it is recommended that the organization authors identified 15 types of workarounds,
an organization. See carefully map and study the current medica- including, for example, affixing patient identifi-
http://www.jointcommission.org/ tion management process and work flows to cation bar codes to computer carts, scanners,
sentinel_event.aspx. ensure a thorough understanding of all the doorjambs, or nurses’ belt rings, and carrying
factors likely to affect the decision-making several patients’ rescanned medications on
process. carts. Thirty-one causes of workarounds were
identified, such as unreadable medication bar
The following factors have been identified as codes, malfunctioning scanners, unreadable
critical to the successful implementation and or missing patient identification wristbands,
sustainability of BCMA12: medications without bar codes, failing bat-
• Teamwork: Developing effective working teries, uncertain wireless connectivity, and
relationships and teamwork is fundamental emergency procedures. The study found
to delivering high-quality patient care. that nurses overrode BCMA alerts for 4.2%
• Information Technology: Information tech- of patients charted and for 10.3% of medi-
nology and systems must be designed to fit cations charted. Possible consequences of
the patient care delivery model. workarounds include medication errors such
• System Integration: All systems must be as wrong doses, wrong times, and wrong for-
integrated to support care provider work mulations administered to patients.13
flow.
• A Clear Care-Delivery Model: Care provid- Use of a management report to cap-
ers and decision makers should develop ture override data. To address the issue of
a clear understanding of the care deliv- missed scans and bar code overrides, Kai-
ser Permanente implemented a preformatted
20
management report to capture override data Independent Double Checks

at the facility, unit, and staff levels to bet-
ter understand BCMA problems leading to To improve medication safety, the concept of
workarounds. Using data from the report an independent double check was developed
and performance improvement methodology, as a final safeguard when administering high-
two Kaiser Permanente facilities decreased alert medications. The independent double
medication overrides from 27% at one facility check is defined in Kaiser Permanente policy
and 13% at the other to 7% and 4%, respec- as a procedure in which two authorized, quali-
tively. Improvement has been sustained, and fied practitioners will separately check each
the facilities now achieve override rates of component of the work process. An example
less than 5% consistently, well ahead of any would be one person calculating a medica-
nationally reported benchmark. tion dose for a specific patient and a second
individual independently performing the same
Process improvement objectives. Process calculation (not just verifying the calculation)
improvements were based on the following and matching the results. The pharmacist will
objectives: be consulted in the event that agreement can-
• Refine the override tracking system to not be reached. As a forcing function in support
support regular reports to each manager of the independent double check, all high-alert
and feedback regarding corrective actions medications are set up in Kaiser’s electronic
to the system lead. medical record to require two staff signatures
• Establish processes to ensure that users before administration.
with patterns of increased avoidable over-
rides are identified and corrective actions Factors in the Independent Double Check
are taken (for example, review patient The two practitioners should check all factors
safety with users, retrain users on scanning applicable to the point of the patient bedside.
technique, and so on). For medications, the factors to be verified
• Develop processes to ensure that nonfunc- during the independent double check may
tioning scanners are identified and include, but are not limited to, the following:
corrected. • Right patient identification using two identi-
• Identify medications (and armbands) with fiers, per local policy
avoidable override patterns and ensure • Right drug, checked per local policy (for
that corrective actions are taken. example, against MAR, physician order,
automatic dispensing machine tape)
CPOE, automated dispensing machines, • Right dose of drug, including the following:
smart IV pumps, and BCMA are all designed ◦ Mathematical calculations using appro-
to enhance patient safety by reducing medica- priate factors and formula (for example,
tion errors and ADEs. However, the success- mg/m2, mg/kg, and so on)
ful implementation and sustainability of these ◦ Strength or concentration of drug
complex systems are, as noted, dependent on • Right route of administration
careful planning and a thorough understanding • Right date and time of administration
of how these new technologies will affect cur- • IV pump setting, if applicable
rent work flows, as well as a multidisciplinary • Rate of infusion, including calculations, if
approach to system design, adequate training, applicable
and ongoing support. And even then, there • Labels
may be yet another safeguard required, as dis- • IV tubing connection and site of line
cussed in the following section. insertion
21
Other factors to be included in the decision- Nurse Knowledge Exchange

making process, as appropriate, include the NKE is a handoff process designed to lever-
following: age teamwork on the unit level and support
• Does the drug’s indication match the nurses during shift changes. It involves the
patient’s diagnosis or condition? patient, supporting interaction between the
• Is this the right formulation of the drug? patient and the care team, with an emphasis
• Is the prescribed dose appropriate for this on safety. NKE has been a great satisfier for
patient? both patients and nurses in improving the effi-
• Is the dosing frequency/timing appropriate ciency and safety of handoffs.
for this patient?
• Is the route of administration safe and In-room SBAR. An important NKE handoff
proper for this patient? element is the in-room SBAR (see Figure 1-1),
• Is the infusion line connected to the right which provides a structured way to hand off
port? information at the bedside. The patients are the
• Have appropriate monitoring tests and focus of the conversation, and they are included
guidelines been prescribed? in discussing their current care and are encour-
aged to ask questions. SBAR is an efficient, safe
Despite being clearly defined in Kaiser’s way to ensure that all parties involved are on the
High-Alert Medication Program (HAMP) (see same page regarding care and medications. It
Sidebar 1-1 on page 7), old habits are hard allows the patients to have confidence that they
to break, and per Nursing Quality Forum feed- are aware of what’s going on and that their infor-
back and through error analysis, it became evi- mation has been exchanged accurately.
dent that the independent double check was
not consistently being implemented. To clarify In-room safety check. Another important NKE
the correct procedure, a group of frontline staff handoff element is an in-room safety check. The
involved in quality improvement made a video off-going and oncoming nurse conduct visual
demonstrating the how-tos and how-not-tos of checks of all IV lines, IV sites, wounds, and other
the independent double check. This video is patient- or unit-specific items. This assures that
posted on the Kaiser Permanente intranet and key safety issues are addressed with the patient
is regularly used to demonstrate the correct at every shift change by two nurses.
way to perform an independent double check.
Health Literacy
Engaging the Patient in Health literacy has been a concern for some
time: On February 7, 2007, The Joint Commis-
Medication Safety
sion released a public policy white paper, What
Ensuring that everyone in the organization is Did the Doctor Say? Improving Health Literacy
committed to medication safety is vital. How- to Protect Patient Safety. Failure to provide
ever, engaging the patient is key in providing patients with information about their care in ways
additional safety to prevent medication errors. that they can understand, the Joint Commission
Kaiser Permanente has addressed this need report warned, will continue to undermine other
by implementing a standardized shift-to-shift efforts to improve patient safety.14
handoff system (which includes the patient),
called nurse knowledge exchange (NKE), and At Kaiser the focus for this topic has been
by incorporating the concepts of health literacy primarily on the sensitization, education, and
in patient education. training of clinicians and health care organi-
zation leaders and staff about health literacy
issues and patient-centered communications.
22
An effective strategy for determining the

“patient usability” of written materials has been
Failure to provide to ask patients on Kaiser’s Patient Advisory
patients with Councils to review the materials and suggest
information about revisions.
their care in ways that
they can understand, Performance Improvement in the
the Joint Commission MedRite Program
report warned, will
continue to undermine Clearly, putting together a successful medica-
other efforts to improve tion safety program is difficult, but it can be
patient safety. done. An example of a successful program
that has utilized knowledge about human fac-
tors as well as the other areas discussed in
this chapter to improve medication safety is
the Kaiser Permanente MedRite program.
Frontline staff have focused on the impor-
tance of easy-to-understand patient education Using performance improvement methodol-
materials and medication instructions pro- ogy, Kaiser developed a model called KP
vided upon discharge. Home health nurses MedRite, to support HAMP (see Sidebar 1-1).
have created diagnosis-specific patient edu- Staff nurses and medication safety leaders
cation booklets that include medication infor- conducted an intensive assessment and rede-
mation, which are given to patients in their sign of the medication administration process
homes. These efforts have improved patient resulting in the development of KP MedRite.
understanding significantly. Through Kaiser’s This process, was designed to safeguard
education/training programs, we not only patients from any medication administration
Defined: Health Literacy
educate providers and patients about the error (MAE), not just those resulting in poten- The report Healthy People
importance and implication of communica- tially devastating effects on patients. Another 2020, published by the U.S.
tion problems but also provide information on impetus for the program was to help ensure Department of Health & Human
how they can communicate with each other Kaiser Permanente’s utmost patient safety Services, defines health literacy
effectively. focus with respect to the Joint Commission’s as “the degree to which individu-
als have the capacity to obtain,
National Patient Safety Goal to improve medi-
process, and understand basic
Communication techniques. The following cation safety.
health information and services
are suggestions for communicating informa- needed to make appropriate
tion to patients: Expectations of Nurses to Multitask health decisions.”15
• Explain things clearly in plain language— Nursing is the last line of defense for patients
for example, don’t use acronyms, medical against MAEs. It is the frontline staff nurse
jargon, difficult-to-understand medical who protects patients and stands as a barrier
terms, and so on. between them and the potential error. Critical
• Focus on key messages and repeat them. thinking paired with habits of vigilance and
• Confirm patient understanding by using the removal of distractions will reduce MAEs.
the “teach-back” or “show me” technique. However, in this age of accomplishing more
• Effectively solicit questions—for example, with less, nurses are under greater pressure
not “Do you have any questions?” but than ever to complete more patient care tasks
“What questions do you have?” during the course of the average shift, includ-
• Use patient-friendly educational materials ing assessment, documentation, education,
to enhance interaction. ambulation, personal hygiene, therapeutic
23
communication, and coordination of care. In

potential competition with the goal of error-free
care is the expectation that nurses bundle pro-
cedures/activities for their patients.16 Nurses Medication
who are highly organized and can deliver the administration time
finest care while demonstrating skill and com- should be considered
passion at the same time are greatly admired. “sacred” time, and that
In fact, nurses are expected to multitask and time is not confined to
be highly efficient while bundling activities in obtaining medications
order to complete required patient care in a from a medication
routine shift.17 station, a medication
room, or a medication
Safeguarding the “Sacred” Safety Zone of delivery system.
Medication Administration
Kaiser Permanente has shifted its focus and
now endorses safeguarding the time when a
nurse should not be multitasking: when the
nurse is administering medications. In fact, Having heard of zones of silence and other
Kaiser has determined that this time should be innovations established around medication
safeguarded to ensure that the nurse admin- dispensing machines, one Kaiser medical
isters the medication as desired and as the center took a brave step. Working with the
patient expects—safely. Medication admin- California Nursing Outcomes Project’s (Cal-
istration time should be considered “sacred” NOC) pilot of structured medication adminis-
time, and that time is not confined to obtain- tration observations to identify opportunities
ing medications from a medication station, a for improvement, the medical center launched
medication room, or a medication delivery sys- a pilot process in 2006 that included the nurse
tem. In fact, nurses should begin to focus on donning noninterruption wear to signal others
the patient and the medication prior to entering that he or she is not to be interrupted. The goal
the medication station area and remain free of was to have a highly visible means to signal
interruptions until the medication has been others that the nurse was involved in an action
safely administered and documented. Medica- that required focus and safety practices. The
tion administration for nurses and the patient noninterruption wear initially selected was an
should be considered a zone of safety just as orange vest, visible from any direction. The
the airline pilot has a zone of safety during the vest was tested with different materials and
descent of a plane. colors, and Kaiser Permanente now offers its
nurses a yellow sash for use during medica-
Signaling to Avoid Distraction tion administration as a noninterruption signal.
Research has shown that distraction can lead Kaiser Permanente was able to see dra-
to errors, and through its KP MedRite program, matic decreases in its medication administra-
Kaiser has worked with frontline staff to safe- tion error rates as measured by the CalNOC
guard the patient experience by focusing on project. The vest or sash in bright yellow has
reducing distraction during medication admin- helped to provide a universal sign to prevent
istration. Registered nurses in one of KPNC’s interruptions.
medical centers worked within each facility’s
Quality Improvement Council to engage man- The success in reducing errors drew attention
agers and frontline nurses in improving medi- internally at Kaiser, and as a result the strategy
cation safety by tackling this issue. spread to all 21 medical centers in Northern
24
California, as well as to other Kaiser Perman- These audits identified several opportuni-
ente regions. KP MedRite’s low-tech process ties for improvement, and action plans were
to alert others within the hospital has provided developed and implemented. In 2008 all Kai-
the nurse with a highly visual means to safely ser medical centers were required to use the
administer medication without distraction or focused Trigger Tool audit. A review of the
interruption. Not only has this process helped data after two quarters provided little action-
to reduce the number of MAEs, but it has also able information. Evaluation revealed that the
given time back to the nurse and the patient Trigger Tool process was very time-consuming
during the course of the shift due to the lack and that the sampling technique was not effec-
of interruptions, which were contributing to tively identifying records of patients who had
increased time in the medication administra- received high-alert medications. The Trigger
tion process. Tool audit as it existed in 2008 was temporar-
ily discontinued so that work could be done at IHI Global Trigger Tool
Triggers are occurrences,
Measurement the regional level to determine other strategies
prompts, signals, or flags found
for performing the Trigger Tool audits using
on review of a medical record
Measurement/monitoring of any medication Kaiser’s automated medical record. that “trigger” further investiga-
safety program is an ongoing process. Fol- tion to determine the presence
lowing the input from Kaiser stakeholders in Currently two Kaiser medical centers are or absence of an adverse event.
response to HAMP (see Sidebar 1-1) that it involved in a research project using the auto- The focus of the Global Trigger
was necessary to explore more actionable mated medical record to detect and evaluate Tool developed by the Institute
metrics, it was decided that because the pro- triggers (including those for errors involving for Healthcare Improvement (IHI)
is on harm, which IHI defines as
cess was stable, auditing could be reduced high-alert medications) that will allow for the
an adverse event in which there
to an annual audit. In the case of permanent measurement of adverse events or harm in
is an injury or any unintended
harm, life-threatening injury, or death from a Kaiser’s system. Results to date are encour- consequence related to the
HAMP error, observational audits are to con- aging in that we no longer have to use sam- delivery of care. Currently, this
tinue monthly for a minimum of three months pling techniques that may or may not “pick up” includes events of commission
or until a 95% compliance level has been all of the high-alert medications administered. only, not omission. A trigger such
achieved, whichever is greater. For 2010 the This makes it possible to focus on patients as an abnormal INR (Interna-
regional average for 21 medical centers was receiving high-alert medications that may have tional Normalized Ratio) is not an
adverse event in itself; it signals
98.5% compliance. resulted in a preventable adverse outcome.
the need to review the appropri-
ate portion of the medical record
Automating the Trigger Tool Utilizing Data on Unusual Events to determine the presence of an
Based on additional input from the Kaiser Since the inception of Kaiser’s work, we have adverse event such as a large
medical centers, the decision was made to used data from our Responsible Reporting retroperitoneal bleed.18 For more
work with the Institute for Healthcare Improve- Forms (“unusual event” forms). These data are information, see the IHI Web site:
ment (IHI) to modify the Global Trigger Tool, analyzed using the control chart methodology http://www.ihi.org.
making it specific to high-alert medications in which one determines whether variations
and, through small tests of change, pilot its from the mean are due to “special cause,” in
use. The use of “triggers,” or clues, to identify this case, the implementation of HAMP. We
ADEs is an effective method for measuring the have seen substantial improvement in Kai-
overall level of harm from medical care in a ser’s volumes of employee-reported medica-
health care organization. tion events and HAMP events. Through these
measurements, we believe strongly that we
Two Kaiser facilities volunteered to pilot the have sustained a new and improved pro-
use of the modified Trigger Tool methodology cess. Although HAMP errors have not been
to focus on the care experience of patients completely eliminated, data for 21 medical
receiving certain high-alert medications. centers through December 31, 2010, show a
25
61% decrease in all reported errors and a 63% the way they did and to determine actionable
decrease in HAMP errors reaching the patient. steps for improvement. Managers and staff will
then work on areas identified and develop and
The Road to Continued implement action plans.
Improvement
The culture survey will be administered again
Kaiser Permanente’s work in medication safety in the first quarter of 2012 to evaluate the
is an unending journey. To reach Kaiser’s goal effectiveness of the action plans. The results
of providing the safest care possible for our of the survey have provided us with an unprec-
patients, efforts to improve the organization’s edented opportunity to identify specific areas
processes and sustain Kaiser’s successes in which we have opportunities to develop
over time are ongoing. Below are details on actions to improve the culture of safety.
measuring some of those successes.
Alignment of Improvements with
Culture Improvement: Culture Survey Existing Work
Results and Actions Kaiser has received feedback from both man-
Beginning in 2002 Kaiser Permanente utilized agers and nursing staff that the number of pro-
a culture survey to measure culture improve- grams and initiatives that are becoming part
ment. We used the survey prior to the start of the work of the unit is overwhelming. Some
of specific initiatives (baseline) and then at nurses have called it “death by initiative.” What
approximately a year after the program was seems to happen is that when units are asked
initiated to measure improvement. Initially the to participate in an initiative or program, there
culture survey was used as a measure for the is a lack of alignment with existing work. With
success of specific human factors interven- work aimed at improving the safety culture, we
tions. Its use spread to new initiatives such as are making a concerted effort to ensure that
Perinatal Patient Safety and Highly Reliable this work is not seen as a separate initiative
Surgical Teams. In line with Kaiser’s increas- or program, but rather we are stressing how
ing recognition that a strong patient safety cul- it aligns with all other work taking place on
ture is key to Kaiser’s goal of being the safest the unit or in the department. As an example,
place to give and receive care, the survey was when we provide tools and assist managers
administered to staff and physicians in all of in working with staff to develop action plans
KPNC’s medical centers, hospitals, and Joint related to the culture survey, we emphasize
Commission–surveyable areas at the end of that actions to improve in these areas are not
2010. The return rate was 85%, with approxi- separate initiatives but rather a key element
mately 23,000 staff and physicians completing of all the other programs and initiatives. And if
the survey. Nurses comprised the majority of a unit chooses ways to improve staff ability to
respondents. “speak up” as an action, that unit needs to look
at all of the current work to see how “speaking
The results received early in the first quarter of up” is necessary for the success of that work.
2011 revealed that we still have opportunities For example, a key behavior for medication
for improvement in several areas key to medi- safety is that nurses “speak up” if an indepen-
cation safety. These include speaking up, dis- dent double check reveals an error, if there is
cussing errors, and resolving disagreements. a concern about a medication error, and so on.
To that end, “debriefings” are being held on
each unit for facilitated discussions with staff Drug Focus Work
and physicians to gain a better understand- Despite regional work on HAMP over the last
ing of why staff responded to the questions in five years, the greatest number of high-alert
26
medication errors (in near misses) is with IV safety program that led to dramatic decreases
heparin infusions. As a result, a regional work in medication errors that cause harm to Kaiser
group has been formed to look at improving Permanente patients.
the reliability of heparin infusions. This effort
is also supported by the Joint Commission’s The success of Kaiser Permanente’s medica-
National Patient Safety Goal on anticoagulant tion safety program in turn led to improvement
therapy. Data about causes of errors over the of the overall patient safety program. One of the
last two years have been pulled and are being things learned from the work was that there was
analyzed to assess for system, work flow, and a lack of knowledge regarding the principles of
human factors. A regional team will be devel- patient safety at all levels of the organization.
oping recommendations for improvement. Kai- To that end, the PSU was developed and aimed
ser’s performance improvement model will be at medical center executive leadership, direc-
used and small tests of change applied. One tors, managers, and chiefs of service as well as
of the first steps in the process will be to hold labor partners. The PSU has now been com-
focus groups with nurses to determine barriers pleted for 19 of KPNC’s 21 hospitals, with the
to performing independent double checks. final two scheduled to take place by the end of
2011. Based on multiple requests from those
attending PSU, Kaiser Permanente developed
PSU2 for direct care providers. The next steps
With work aimed at in this area are to develop a PSU for support
improving the safety staff and to develop a refresher university for
culture, we are making leadership.
a concerted effort to
ensure that this work is As part of the patient safety program, Kaiser
not seen as a separate Permanente introduced standardized tools and
initiative or program, processes, including human factors training
but rather we are tools that can be used by staff. For example,
stressing how it aligns the KP MedRite program that was developed
with all other work as part of the medication safety work illus-
taking place on the trates consideration of the difficulty human
unit or in beings have in performing safely when there
the department. are multiple interruptions and distractions. To
reduce these interruptions and distractions,
tools and techniques such as noninterruption
wear and zones of silence were put in place.
The process of using a common communica-
Summary and Next Steps tion tool (SBAR) and including the patient in
The tragic death of a patient due to a pre- shift handoffs are other examples of how an
ventable medication error led KPNC to an area important to the safety of the patient
examination of the entire medication delivery were improved by standardization. Moving
system. Working with nursing leaders, front- forward, Kaiser Permanente will also continue
line nurses, and other members of the health to implement into patient safety programs the
care team, Kaiser Permanente studied its knowledge and application of human factors
systems by applying the principles of human principles outlined in this chapter.
factors theory. Armed with the knowledge
gained from this investigation, Kaiser was able The use of technology as another means of
to develop and sustain HAMP, a medication reducing errors has been very effective in
27
Kaiser programs. CPOE and BCMA are now the safety of the system or the safety of the
in place at our 21 medical centers. Although patients.
technology has significantly reduced certain 2. Kaiser Permanente must develop a
types of errors, the organization constantly process that makes it easy to discuss and
keeps in mind that technology, if not used learn from errors.
properly, can introduce other problems into the 3. Kaiser Permanente must develop systems
system that can lead to errors. and provide tools and education related
to having “difficult conversations,” so that
Measurement is key in determining if the sys- discussions focus not on who is right but on
tems that were put in place as part of Kaiser’s what is right for the patient.
medication safety programs are accomplish-
ing the intended outcome. The plan is to con- Patient safety is an ongoing journey. At Kaiser
tinue the research being performed by using Permanente, continually striving to become
the automated medical record to detect and the safest place to give and receive care is the
evaluate triggers that will allow identification desired outcome.
of, and enable us to learn from, preventable
adverse outcomes. References
1. Aspden P., et al. (eds.), Committee on Iden-
While working to improve the safety of the med- tifying and Preventing Medication Errors,
ication delivery process as well as all the other Institute of Medicine: Preventing Medication
parts of the system that affect the safety of the Errors, Quality Chasm Series. Washington, DC:
patient, it has become abundantly clear that a National Academies Press, 2007.
key to success is developing, sustaining, and 2. National Quality Forum (NQF): Safe Practices for
weaving a culture of safety into the “way busi- Better Health Care—2006 Update: A Consensus
ness is done.” The just culture work has been Report. Washington, DC: NQF, 2007.
important and continues to guide Kaiser Per- 3. Leape L.L.: Error in medicine. JAMA
manente leaders on that journey, but there are 272:1851–1857, Dec. 21, 1994.
other elements of a culture of safety that must 4. Williams J.C.: Assessing the Likelihood of Viola-
be embedded within the organization. In hind- tion Behaviour: A Preliminary Investigation.
sight, there should have been a completed cul- Manchester, U.K.: Dept of Psychology, Univer-
tural assessment of each hospital much earlier sity of Manchester, 1996.
in the patient safety journey. The data received 5. Baker A., Simpson S., Dawson D.: Sleep
from the culture survey have been invaluable in disruption and mood changes associated with
helping to focus on areas identified to improve menopause. J Psychosom Res 43:359–369, Oct.
the culture. Over the next few years, Kaiser 1997.
Permanente’s intent is to use the findings from 6. Rogers A.E., et al.: The working hours of hospi-
this survey to focus on and improve those tal staff nurses and patient safety. Health Aff
areas that nurses and other providers identify (Millwood) 23:202–212, Jul.–Aug. 2004.
as in need of repair. Direct care providers have 7. Advisory Board Company White Paper:
made it clear in their survey responses as well Collaborating for Outcomes. 2010.
as in their debriefings around the results of the 8. American Nurses Association: Position State-
culture assessment that three major areas are ment: Just Culture. Jan. 28, 2010.
in need of improvement: http://www.justculture.org/Downloads/
1. Kaiser Permanente must make it easy and ANA_Just_Culture.pdf (accessed Jun. 27,
safe for all staff to speak up, not only about 2011).
errors but anytime there is a concern about 9. Bates D.W., et al.: Effect of computerized physi-
cian order entry and a team intervention on
28
prevention of serious medication errors. JAMA 16. Bates D.W., et al.: Patient risk factors for
280:1311–1316, Oct. 21, 1998. adverse drug events in hospitalized patients.
10. Oren E., Shaffer E.R., Guglielmo B.J.: Impact ADE Prevention Study Group. Arch Intern Med
of emerging technologies on medication errors 159:2553–2560, Nov. 22, 1999.
and adverse drug events. Am J Health Syst Pharm 17. Pape T.M.: Applying airline safety practices
60:1447–1458, Jul. 15, 2003. to medication administration. Medsurg Nurs
11. Poon E.G., et al.: Effect of bar-code technology 12:77–93, Apr. 2003.
on the safety of medication administration. 18. Griffin F.A., Resar R.K.: IHI Global Trigger Tool
N Engl J Med 362:1698–1707, May 6, 2010. for Measuring Adverse Events, 2nd ed. Institute
12. Straub D.A.: What nurses want pharmacists for Healthcare Improvement (IHI) Innovation
to know about bar coding processes. Pharmacy Series white paper. Cambridge, MA: IHI, 2009.
Purchasing & Products 3:20–21, Dec. 2006.
13. Koppel R., et al.: Workarounds to barcode
medication administration systems: Their occur-
rences, causes, and threats to patient safety. J Am
Med Inform Assoc 15:408–423, Jul.–Aug. 2008.
14. The Joint Commission: What Did the Doctor
Say?: Improving Patient Safety. Oakbrook
Terrace, IL: The Joint Commission, 2007.
15. U.S. Department of Health and Human
Services, Health Resources and Services Admin-
istration: About Health Literacy.
http://www.hrsa.gov/publichealth/
healthliteracy/healthlitabout.html (accessed
Aug. 2, 2011).
29
FOCUS: High-Alert Medications
FOCUS
High-Alert Medications:
Opioids in Home Care, Hospice, and Behavioral Health Care Settings
Regardless of the health care setting, each organization must decide which medications that
it administers are considered high-alert, meaning that these medications can cause patients
significant harm when they are used in error.1 Lists of high-alert medications are available
online from such organizations as the National Institute for Occupational Safety and Health
(NIOSH) and the Institute for Safe Medication Practices (ISMP). Any medications with a
U.S. Food and Drug Administration (FDA) black box warning should be considered high-
alert as well.
When the ISMP published its first list of high-alert medications in 1989, only six medications
were on the list. One of these was an opiate—morphine—and opiates have continued to be
among the most frequent high-alert medications to cause harm.2 A few high-alert medications,
including opiates, may be particularly pertinent to certain clinical settings. The following is
helpful information for nurses on the use of selected opioids in home care, hospice, and behav-
ioral health care settings.
Fentanyl Transdermal Patch

Fentanyl transdermal patches provide continuous pain relief to opioid-tolerant patients in
home care, hospice, and other health care settings. Physicians have made errors when they
prescribe this medication to opiate-naïve patients who may need only acute, short-term pain
relief.3 According to the package insert for the fentanyl transdermal patch, patients should not
start using the transdermal route of pain relief unless they are taking one of the following: at
least 60 milligrams (mg) of oral morphine daily, at least 30 mg of oral oxycodone daily, at least
8 mg of oral hydromorphone daily, or an equally strong dose of another opioid for a week or
longer. If a patient is not sufficiently opioid tolerant but is prescribed the transdermal form of
fentanyl, he or she is at increased risk for adverse effects due to overdose, including troubled
or shallow breathing, extreme sleepiness or sedation, confusion, feeling faint, or an inability
to think, talk, or walk normally. And, unfortunately, errors in prescribing, dispensing, and
administering transdermal fentanyl have also resulted in numerous fatalities.4
Nurses’ management of fentanyl transdermal patches. When nurses are taking care of
patients who are prescribed fentanyl transdermal patches, they must do the following4:
• Validate the Appropriateness of the Medication: Validate that the patient has chronic pain,
is opioid tolerant, and does not have respiratory issues that would contraindicate the
medication.
• Provide Education on How to Use the Medication: Assess if the patient and/or caregiver
understands how to use the medication (for example, applying only one transdermal patch
at a time—and being careful to remove previous patches—to clean, dry skin on the chest,
back, flank, or upper arm). If necessary, demonstrate how to apply the patch.
31
FOCUS
(continued)
• Consider Response to Side Effects: Assess if the patient and/or caregiver can seek medical
attention for serious side effects (such as trouble breathing or feeling faint).
• Provide Education on Factors Affecting the Medication: Make sure patients and/or caregivers
understand that patients’ blood levels of fentanyl may rise if they (1) are exposed to a heat
source such as a heating pad or hot tub, (2) have a temperature of > 102°F (38.9°C), or (3)
drink alcohol.
• Provide Education on Safe Disposal of the Medication: Ensure that the patient or caregiver
knows how to safely dispose of the medication properly: Fold the patch in half, with sticky
sides facing each other, and flush down the toilet. Note that flushing patches down the toilet
may not be allowed in some places, so advise per state and local laws and regulations.
A helpful video. For more information on fentanyl transdermal patches, providers can access
a free FDA patient safety video at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/
transcript.cfm?show=44#2.
Opioids and Antianxiety Medications at End-of-Life

Primary medications provided to hospice patients at the end of life are opioids for pain as
well as antianxiety medications. Family members are primarily responsible for administering
these medications even though this type of drug regimen is complex and requires careful man-
agement.5 For example, many of the medications prescribed in hospice are on an as-needed
(or PRN) basis, so family members need to make judgment calls as to when the medication
should be given. The decisions are based on the patient’s symptoms rather than on a specifi-
cally prescribed schedule. Even though 80% of family members report managing medications
for hospice patients in the home, less than 60% of those family members received medica-
tion management assistance from hospice care providers.4 As a result, family members report
feeling inadequately prepared to administer end-of-life medications, and patients experience
inadequate control of their symptoms.5
Nurses’ management of opioids and antianxiety medications. When hospice providers,

including nurses, explain the process of dying and describe symptoms that the patient will
likely experience (such as pain, shortness of breath, and anxiety), they should also provide
information about the medications used to treat those symptoms. Nurses should therefore do
the following as part of the patient and family education on these drugs:
• Demonstrate how to administer these medications.
• Explain which medications cannot be crushed.
• Describe how long it will take for the medication to take effect.
• Describe any adverse effects that could result from the medications.
32
FOCUS
(continued)
Family members may resist giving patients opioids because they fear the patient will become
addicted, it will make them too drowsy, or it will speed up the dying process.5 Thus, hospice
providers should assess family members’ preconceived notions about opioid and antianxiety
medications and provide education on these medications when necessary.
Analgesic algorithms. Nurses in home care can refer to analgesic algorithms provided by the
National Hospice and Palliative Care Organization to ensure that the patient’s pain is managed
appropriately. They can also use the algorithms as a means to educate family members on provid-
ing adequate pain relief.
Self-Administration in Opioid Addiction Treatment Programs

Joint Commission–accredited behavioral health care organizations that prescribe, dispense, or
store medications must comply with Medication Management (MM) Standard MM.06.01.03,
which states, “Self-administered medications are administered safely and accurately.”
Individuals with mental illness receiving services in behavioral health care settings may be at
increased risk for medication errors when they self-administer medications. Those who receive
care in outpatient settings, such as community behavioral health clinics, may be even more at
risk because their medication administration regimen is not under daily scrutiny by a health
care professional as it would be in an inpatient setting. The Joint Commission recognizes
the special circumstances and needs of such clinics. Joint Commission requirements for self-
administration at one type of community-based program—opioid addiction treatment pro-
grams—are described in the following section.
Standard MM.06.01.03. Opioid addiction treatment programs seeking Joint Commission

accreditation should implement the following requirements in accordance with Medication
Management (MM) Standard MM.06.01.03:
• Create written policies for allowing unsupervised or “take-home” doses of opioid medica-
tions based on physical judgment and staff assessment of the individual’s behavior. (Policies
cannot prohibit take-home doses for all individuals served because that would not allow for
individualized care.) These policies should also consider exceptional circumstances when
individuals may be given additional doses of take-home opioid medications on a temporary
basis (such as family emergencies). Finally, the policy should determine an individual’s eli-
gibility for take-home doses of opioid medications on days when the program is closed.
• Although a physician makes the final decision to approve individuals for take-home opioid
medications, a multidisciplinary team provides recommendations and input. When deter-
mining if individuals are eligible for take-home doses of opioid medications, consider the
following:
33
FOCUS
◦ Absence of recent drug use (including alcohol)

◦ Regular clinic attendance
◦ Absence of serious behavior problems at the clinic
◦ Absence of recent known criminal activity (such as drug dealing)
◦ Stable home environment and social relationships
◦ Length of time in maintenance treatment (for example, for the first 90 days of treatment,
there is a maximum of one unsupervised dose per week)
◦ Confidence that the take-home medication can be safely stored within the individual’s
home
◦ Benefit obtained from decreasing clinic attendance in relation to potential risks of
diversion
• When a decision is made regarding home use of opioid medications, the physician will doc-
ument the reasons in the individual’s record. In addition, the decision regarding take-home
opioid medications is reviewed periodically and documented in the individual’s record.
• When the individual is allowed to take opioid medications home for an unsupervised
dose(s), he or she is given the medication in a childproof container and instructed how to
keep the medication secure.
References
1. Institute for Safe Medication Practices (ISMP): ISMP’s List of High-Alert Medications. 2008.
http://www.ismp.org/tools/highalertmedications.pdf (accessed Apr. 17, 2011).
2. Institute for Safe Medication Practices (ISMP): High-alert medication feature: Reducing patient harm
from opiates. ISMP Medication Safety Alert! Acute Care, Feb. 22, 2007. http://www.ismp.org/Newsletters/
acutecare/articles/20070222.asp (accessed Aug. 16, 2011).
3. Institute for Safe Medication Practices (ISMP): Ongoing, preventable fatal events with fentanyl transder-
mal patches are alarming! ISMP Medication Safety Alert! Acute Care, Jun. 28, 2007. http://www.ismp.org/
Newsletters/acutecare/articles/20070628.asp (accessed Apr. 15, 2011).
4. Food and Drug Administration: Fentanyl Transdermal Patch: Important Information for the Safe Use of
Fentanyl Transdermal System (Patch). Updated Jun. 18, 2009. http://www.fda.gov/Drugs/DrugSafety/
PostmarketDrugSafetyInformationforPatientsandProviders/
DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm048721.htm
(accessed Apr. 15, 2011).
5. Lau D.T., et al.: Family caregiver skills in medication management for hospice patients: A qualitative
study to define a construct. J Gerontol B Psychol Sci Soc Sci 64:799–807, Nov. 2009.
34
CHAPTER TWO MEDICATION SAFETY:
Using Technology
AUTHORS: Brigham and Women’s Hospital, Boston—Anne D. Bane, R.N., M.S.N., Director, Clinical
Systems Innovations, Center for Nursing Excellence; Carol J. Luppi, R.N., B.S.N., A.L.M., Nurse Educator
for Technology, Center for Nursing Excellence; Laura Mylott, Ph.D., R.N., Director of Nursing Education,
Innovation, and Evidence-Based Practice, Center for Nursing Excellence; and Patrice K. Nicholas, D.N.Sc.,
M.P.H., R.N., A.P.R.N., B.C., F.A.A.N., Director of Global Health and Academic Partnerships, Center for
Nursing Excellence, and Professor, MGH Institute of Health Professions Graduate Program in Nursing
As the nursing profession and patient safety Recent technological advances offer possibili-
initiatives have evolved, approaches to medi- ties for maximizing patient safety and enhanc-
cation administration have also changed. ing the role of nursing by engineering a safer
In the 1970s and 1980s, many work set- work environment. This chapter focuses on the
tings advocated for a team approach, with nurse’ s role in the use of technology to reduce
one nurse assigned to the role of “medica- medication errors and adverse drug events
tion nurse,” who was responsible for deliv- (ADEs). It addresses the current problems
ery of medications to many patients. Current with medication errors, discusses technologi-
practice has evolved to an individualized cal innovations, reviews the role of the work
ө
approach, with each nurse involved in the environment, and covers implications for pro-
steps of the medication management process fessional practice. The nurse authors of this
for his or her assigned patients: prescribing, chapter will share their experience at Brigham
procuring, dispensing, and administering the and Women’s Hospital (BWH) in Boston as it
drug, and monitoring the patient’s response. relates to the nurse’s role in medication safety
Partially due to the focus on patient safety and technological innovations. BWH is a large,
in the twenty-first century—and in large part academic medical center with a long history of
due to advances in technology—the medica- designing, implementing, and sustaining inno-
tion management process itself has evolved in vative safety technologies for medication man-
many hospitals. For example, it has changed agement. In addition, the chapter will examine
from the use of handwritten prescriptions and recent literature on nurse’s satisfaction with
delivery of doses in pill cups to the use of technology-enhanced medication administra-
technologies such as computerized provider tion. The literature on nurses’ critical thinking
order entry (CPOE) with clinical decision sup- processes with technology to enhance medi-
port systems (CDSSs), bar code medication cation safety will be reviewed, as will advances
administration (BCMA), automated dispensing in medication safety and the growth of medica-
machines (ADMs), electronic health records tion administration technology globally.
(EHRs), electronic medication administration
records (eMARs), smart pump technology,
and infusion devices.
35
Medication Errors and management system standardized the medi-

Technology cation administration processes, decreased
Technology and Teams
Interdisciplinary teamwork is a time for processing medications in the phar-
recognized need internationally Many in health care have looked to technologi- macy, and increased the accuracy and safety
as well as in the United States. cal advances to solve the problem of medica- of the medication administration process.3
In 2001 the Canadian Patient tion errors. Yet, despite advances in technology, Working in such teams requires an integrated
Safety Institute was developed medication errors still occur. In a large academic medication management system. In their sem-
in collaboration with the Royal medical center, Cina et al. found that 23.5% of inal studies, Leape et al.5 and Classen et al.6
College of Physicians and Sur-
undetected errors related to medications were described medication management in hospi-
geons of Canada to coordinate
a strategy to improve patient
potential ADEs, of which 28% were serious and tals as a series of interrelated steps involving
safety throughout the country. A 0.8% were life threatening. The most common at least three disciplines—physicians, nurses,
key aspect of the organization’s potential ADEs were caused by incorrect medi- and pharmacists—and proposed that a major-
collaborative effort is a focus on cations (36%), incorrect strength (35%), and ity of medication errors are attributable to inef-
using technology and enhancing incorrect dosage form (21%).1 Several recent fective systems that surround care providers
interdisciplinary teams.8 studies suggest that BCMA systems success- and thus are potentially avoidable. Crane and
fully track, reduce, and prevent bedside medica- Crane offered a solution based on a systems
tion errors; however, bar codes cannot prevent approach of failure mode and effects analysis
many errors that can occur when drugs are (FMEA).4 They suggest that FMEA in combi-
restocked, such as storing look-alike/sound- nation with emerging technologies such as
alike (LASA) drugs in the same drawer. Nor a CDSS with integrated real-time medical
can the use of smart infusion pumps prevent all informatics, EHRs, CPOE, BCMA, ADMs,
errors with intravenous (IV) drug administration: and robotics will limit medication errors in the
In clinical practice settings, pressing one wrong future. Notably, Crane and Crane suggested
key during ordering or calibration of an infusion that the key elements for success in prevent-
pump can result in a serious medication error, ing medication errors are building the interdis-
notwithstanding the support the systems and ciplinary team, adopting a systems approach,
technology can provide. and focusing on a cost/benefit analysis.4
Defined: FMEA
Failure mode and effects analy-
Interdisciplinary Teams and Technology
sis (FMEA) is a systematic group
The solution may lie in having systems and
of activities aimed at recogniz- An interdisciplinary
ing and evaluating the potential technology in place to support the work of an
team approach to
failures of a product or process interdisciplinary team that includes nurses.
ordering, dispensing,
and the effects of those failures, An interdisciplinary team approach to order-
administering, and
identifying actions that could ing, dispensing, administering, and evalu-
evaluating medications
eliminate or reduce the chance of ating medications is necessary for patient
potential failures occurring, and is necessary for
safety. Recent literature suggests that phar-
documenting the entire process.8 patient safety.
macists, nurses, and physicians should work
in interdisciplinary teams.2–4 Carrington et al.
described the importance of working in an
interdisciplinary team to develop consensus Both nursing and pharmacy point-of-care
guidelines for the safe prescribing, dispens- systems (systems in the clinical environ-
ing, and administration of chemotherapy by ment)—including eMARs with bar code
a working group of the Clinical Oncological scanning, ADMs, smart infusion pumps, and
Society of Australia.2 And in their interviews CPOE—are still at risk for medication errors
of an interdisciplinary group of staff, Skibin- even with support of technology designed to
ski and colleagues found that the implemen- reduce that risk. When implemented correctly,
tation of new technology in the medication however, a place for technology still exists in
36
CHAPTER TWO: Medication Safety: Using Technology
the medication management system. Skib- that nurses manage highly complicated pro-
inski et al. found that implementation of new cesses and environmental issues in the midst
Technology Acronyms
technology into the medication management of delivering individualized care.14,15 Errors can The acronyms listed below will
system standardized the medication admin- result from a multiplicity/variety of both human be used repeatedly throughout
istration processes, decreased time spent on factors and system failures. Examining the this chapter—and by nurses in
tasks associated with the medication order- nurse’s role in medication administration within their roles as they interact with
ing process (for example, elimination of order the context of outcomes-based patient care, technology. Definitions will be
transcription and the need to interpret illegible but delivered as a process within the complex- provided in the context of chapter
discussions regarding these
handwriting), and increased accuracy of medi- ity of a system, enhances the understanding
technologies.
cation administration to patients.3 of the causes of error and reveals opportuni-
ties for individual and systems interventions. CPOE: computerized provider
Technology and Challenges for (For more on the role of human factors and order entry
systems in medication error, see Chapter 1.) CDSS: clinical decision support
Nurses Related to Medication
In addition, analyzing and measuring nurs- system
Management Practices ing work flow is essential in the integration of BCMA: bar code medication
Nurses administer medications directly to technology-based medication administration administration
ADM: automated dispensing
patients more often than any other care pro- systems.9 Organizations need to know the
machine (or ADC, automated
vider. Keohane and colleagues found that tasks nurses perform each day and at what
dispensing cabinet)
acute care nurses spend 27% of their time on times of the day so that new technologies EHR: electronic health record (or
medication administration activities.9 Despite support nurses’ work flow and maximize their EMR, electronic medical record)
implementation of technology, incorrect medi- time with patients. (See “Staff Nurses as Key eMAR: electronic medication
cation administration is responsible for the Process and Practice Consultants” on pages administration record
largest number of harmful medication errors10 34–40.)
and is the second most common source
of medication error.10–12 Why is medication Technology to Address Lack of
administration, in particular, so vulnerable to Medication Information
errors? Lack of knowledge about medications, specifi-
cally correct preparation and correct adminis-
The Complexity of the Medication tration techniques, is a leading cause of errors
Administration Process affecting medication administration and other
Medication administration is a clinical act with parts of the medication management pro-
both independent and collaborative compo- cess. Examples of problem practices include
nents that nurses perform on behalf of patients administering undiluted medications, crush-
while providing direct and indirect care, including sustained release compounds, and using
ing documentation and collaboration with the incorrect intravenous tubes for drug admin-
interdisciplinary team. It is also an activity istration.10 Taxis and Barber reported that
based on clinical judgment and specialized most errors in administering IV medications
knowledge.13 The patient’s state of physiologi- occurred because nurses administered bolus
cal and psychological health and response doses faster than recommended.16 These
patterns, and goals of care all need to be con- problems have been attributed to the lack of
sidered to safely carry out medication admin- convenient and current resources at the point
istration. As noted earlier, however, nursing of care and a lack of available experienced
care is collaborative and also occurs within the nursing resources.10 Fortunately, the wide-
context of a large and complex system of care. spread implementation of computers in acute
care hospitals has made current medication
Human factors, system failures, and work information more available at the point of care,
flow. Recently published research suggests and newer computerized infusion devices (or
37
smart pumps) have extensive drug libraries. representation of nurses is vital in each.
In addition, clinicians are increasingly using Although nurses normally physically adminis-
handheld computers during patient care.17 Fur- ter medications, safe practice requires coordi-
ther study is needed to determine the impact nation, communication, and proper function of
of this technology on medication error and to multidisciplinary teams.19,20 Nurses need to do
examine how and why nurses use (or don’t the following to promote safe practice21:
use) these supports in everyday practice. • Provide leadership for interdisciplinary
planning teams that promotes an environ-
Nurses’ Decision Making in Medication ment of collaboration and not blame.
Management Practice • Serve as key practice and process
Medication management practice requires consultants.
intensive critical thinking skills and is integral • Participate in all education and communi-
to holistic, professional nursing care. Safe cation initiatives.
medication management practices are the • Provide ongoing support for medication
result of both the nurse’s clinical, environmen- safety.
tal, and patient-related knowledge and of the • Participate in surveillance and quality assur-
work flow patterns shaped and supported by ance strategies that promote medication
the system in which nurses practice. Although error transparency and timely communi-
advances have been made in improving medication to the entire community regarding
cation practices, particularly regarding tech- errors and error mitigation.
nological supports, a deeper understanding of
how nurses make decisions related to medica-
tion management and the effects of the envi-
Nurses need to
ronment and work flow on decision making is
recognize that
needed.
although technology
can prompt and cue
Nurse Involvement in Choosing steps in the medication
and Integrating Technology management process,
it can never be used
Using technology may reduce medication to replace critical
errors and improve patient safety; however, thinking.
any technology integration plan is merely a
tool. Nurses need to recognize that although
technology can prompt and cue steps in the
medication management process, it can never Furthermore, the 2006 Institute of Medicine
be used to replace critical thinking. To achieve report Preventing Medication Errors further
the intended safety goals, all patient safety suggests that nurses and other health care
technologies must be brought into an insti- providers should “create high-reliability orga-
tutional culture of safety, support evidence- nizations that constantly improve the safety
based interdisciplinary practice, and possess and quality of medication use.”22(p. 2) And when
an intuitive physical design.18 the Erice Medication Errors Research Group
(EMERGE) met in July 2008 in Erice, Sicily,
There are essential components to any to formulate recommendations internation-
effective technology integration plan, and ally, chief among their recommendations were
38
the following: integration of medication error approval, project design, and resolution of
reduction in health professions education, high-level decisions. Project managers from
application of data from tracking systems to each clinical discipline are essential to under-
reduce errors, engagement of the interdisci- stand the practice issues and the implications
plinary team, use of health information tech- of using technology to automate the complex
nology (HIT), and development of a culture process of medication management. Nurses
that promotes communication.23 must put forward a strong presence in this pro-
cess because the designs of these technolo- Defined: HIT
Nurses as Key Members of the gies have such a significant impact on nursing Health information technol-
Interdisciplinary Team practice. ogy (HIT) encompasses many
As noted earlier, the formation of interdisci- electronic resources enhancing
plinary teams is recommended to support Staff Nurses as Key Process and Practice clinical decision support, sharing
improvements in the integration of technology Consultants health care data, exchanging
clinical information in real time,
within medication management systems. To Koppel et al. discuss the success of any safety
and facilitating communication
help ensure the success of the integration, the system being dependent on designing tech-
among care providers.
interdisciplinary team—nurses, physicians, nology that promotes intentional use and sup-
pharmacists, health information services ports the work flow demands of clinicians.19 As
(medical records personnel), and information mentioned previously, work flow is a critical
system specialists (computer analysts and consideration. When incorporation of tech-
software developers)—must first create an nologies does not take nursing work flow into
institutional strategy for the use of technology consideration, nurses will resist changing their
in medication management. practices and fail to integrate the new technol-
ogy by devising detrimental behaviors or work-
Executive sponsorship. First steps include arounds that override the safety systems.18,26
articulating a clear case for organizational
investment in the technology to obtain execu- The primary aim of automating the medication
tive sponsorship, which may help in ensuring administration process is to improve accu-
coverage of start-up equipment costs, staff racy and patient safety; potential long-term
development expenses, and ongoing mainte- improvements in efficiency are a second-
nance costs.21 Senior nursing leaders, man- ary consideration. Historically, the standard
agers, and influential staff nurses are much of nursing practice has been use of the “five
more likely to embrace a project if it is sup- rights” of medication administration: right drug,
ported by the chief nursing officer. A strong dose, route, time, and patient. The staff nurse
organizational commitment to patient safety is the expert consultant for hardware and
and reducing medication errors through the software designed to automate this practice,
use of technology must be consistently com- because he or she is intimately aware of all
municated from the chief executive level and mitigating factors. Staff nurses are not likely to
throughout the institution.24,25 be directly involved in designing the hardware
and software, but their consultation in select-
Team structure. The interdisciplinary team ing technology designed by others is critical.
should be organized in various committee
structures with distinct responsibilities, in coop- Change champions and change resistors.
eration with administrative protocol for commit- Nurses selected to participate in this pro-
tee formation. A steering committee consisting cess should include a balance between those
of executive sponsors and discipline-specific who typically champion practice change and
project managers should oversee the project those who are usually resistant and critical.
and provide leadership authority for product The need for staff nurses to serve as change
39
champions for their peers is well-documented

in the literature.27–29 It is, however, also criti- Testing these policies
cal to engage with influential, informal lead- and designs in the
ers who may be resistant to change to elicit clinical setting is vital,
their valuable advice regarding the potential because the reality of
weaknesses of any new technology systems the complex medication
in medication management. Getting staff to management practice
spend time on the process of implementing cannot be adequately
technology is challenging and requires some captured in a
type of scheduled focus group activity at criti- simulated setting.
cal junctures in a project. This is one example
of how executive sponsorship of a project is
required to enable staff nurses to leave the
bedside to complete this essential work. underestimated. Nursing education special-
ists should be consulted to create the educa-
Testing in the clinical setting. After the tion plan and content. Technology education
design phase is completed (with input from designed by technology experts often pro-
staff nurses), successful technology integra- vides a comprehensive review of all the fea-
tion plans should include detailed policies, tures of the technology and does not focus on
procedures, and guidelines for practical appli- how the end user will integrate the technology
cation of the technology created by the mul- into practice. There is an opportunity for using
tidisciplinary team. Testing these policies and e-learning (computer-based learning) as an
designs in the clinical setting is vital, because introduction to the new technology; however,
the reality of the complex medication man- e-learning modules must be supplemented
agement practice cannot be adequately cap- with hands-on classroom instruction that simu-
tured in a simulated setting. Issues should lates the clinical application of the product as
be expected/anticipated to surface during the well as with peer support during implementa-
pilot test that will require modifying technology tion in the clinical setting.
design and function. It is essential to plan for
extra time to enhance software and hardware Nurse super-users. A technology education
prior to a full technology implementation. This model used at Brigham and Women’s Hos-
pilot test will also provide an opportunity to pital, Boston, for eMAR training included all
evaluate the education plan. these elements: e-learning introduction, class-
room instruction, and peer support. The most
Nursing Input Integral to Technology vital element of this model was using peer
Education Plans education and support in the role of the nurse
Thorough training is necessary for all disci- super-user or nurse coaches.31 A core group
plines during all phases of technology imple- of staff nurses from every clinical area of the
mentation.30 To achieve the optimal safety hospital transitioned to a full-time temporary
benefits of any technology, the end users need support role. They were provided with special-
a comprehensive understanding of how to use ized and intensive training regarding the new
it, when to use it, and why to use it. Proper technology, change theory, and conflict reso-
use of the technology is critical to the success lution. This group was used to provide class-
and accuracy of the system.19 The amount of room education and live support during the
time and funding required to provide educa- phased implementation process in the clinical
tion that promotes this type of comprehen- areas while acting as essential change agents
sive understanding of the technology is often for the project. After the new technology was
40
fully deployed, these super-users returned to these technologies are not discovered until they
their original staff nurse roles and provided a are “live” (fully operational) in an organization
matrix of technology expertise throughout the despite rigorous testing prior to implementation.
institution. Constant vigilance and feedback from end users
is necessary to avoid negative outcomes such
Experience with the technology. Even with as workarounds of these systems.32 Prompt
heavy investments in staff education and sup- response to feedback is just as essential to earn
port, integration/adoption/absorption of the continued support from end users.
new technology is not guaranteed because
some staff members are very resistant to prac- Use of safety rounds. Safety rounds by
tice change. The best champions of any safety members of the interdisciplinary implementa-
technology are often those who have first- tion team provide an opportunity for observ-
hand experience of the technology preventing medication management practices directly,
ing patient harm. Creating opportunities and which has been shown to be more accurate24
vehicles for communication of these close-call than the traditional submission of ADE incident
stories will increase acceptance and integra- reports. Fear of reprisal and peer censure,
tion of the new technology. unrecognized medication error, a perceived
lack of danger, and competing patient care
Nursing Involvement with Support and priorities all contribute to underreporting of
Surveillance ADEs.33 The success of the interdisciplinary
After the new technology is fully integrated implementation team is dependent on a cul-
throughout an institution, continued support of ture of safety that is defined by a nonpunitive,
the end user and enhancement of the system empowering response to human errors and
are necessary to sustain its use. Support for a meticulous scrutiny of medication manage-
the staff nurse should include human and com- ment systems.20,32–34 (For more information on
puterized resources for technical use and clini- these topics, see Chapters 1 and 4.) Many of
cal application of the technology at the point the technical components of the medication
of care. Examples include unit-based experts management system afford the team valuable
such as staff nurse super-users/coaches, quality data that illustrate the end users’ inter-
regularly scheduled safety rounds by the interaction with the technology. Regular analysis
disciplinary implementation team, 24-hour of these quality data can reveal opportunities
phone access to backup technical and clini- for system enhancements that promote the
cal resources, and access to online instruc- intended use of the safety technology.
tion manuals. An opportunity for face-to-face
communication between the staff nurses and
the interdisciplinary leaders cannot be over-
emphasized. The presence of these leaders Many of the technical
at the point of care stimulates essential feed- components of
back regarding the technology and reinforces the medication
the staff nurse’s contribution to patient safety management system
during the medication management practice. afford the team
valuable quality data
End-user feedback. Sustaining these technolo- that illustrate the end
gies is dependent on this end-user feedback. users’ interaction with
Updates need to occur regularly to continue the technology.
supporting the nurses’ work flow at the bed-
side. Many of the unintended outcomes of
41
FIGURE 2-1. Components of Closed-Loop, Point-of-Care Medication

Administration System at Brigham and Women’s Hospital
KEY: CPOE: computerized provider order entry; eMAR: electronic medication administration record; RN: regis-
tered nurse; IV: intravenous medication; AUTO-ID: automatic identification; Pharm.: pharmacy; BWH: Brigham
and Women’s Hospital.
Source: Brigham and Women’s Hospital, Boston. Used with permission.
Technology That Supports

Tan Tock Seng Hospital, both in Singapore,
the Nurse in Medication jointly received the Singapore National Info-
Management Practice comm Award in 2010 for the most innovative
use of IT (information technology) in the public
A variety of technologies exist to support the sector for their implementation of a closed-loop
nurse’s role in medication management practices, medication management system designed to
yet benefits and limitations should be considered improve patient safety by reducing medication
in using technology for medication management. errors, to achieve secured and timely supply
Technology that supports the role of the nurse in of medications, and to work efficiency through
the practice of medication management must be automation by redesigning work processes to
part of a closed-loop, point-of-care medication focus on patient-centric activities (see Figure
management system that supports the process 2-2 on page 43). From 2007 to 2009, they pro-
from ordering through administration to surveil- gressively implemented electronic solutions
lance (see Figure 2-1 above). for prescribing, dispensing, and medication
administration that yielded dramatic patient
Similar systems have emerged across the safety and staff satisfaction results.35
globe. The National University Hospital and
42
FIGURE 2-2. Work Flow for Closed-Loop Medication Management (CLMM)

System in National University Hospital and Tan Tock Seng Hospital, Singapore
KEY: eiMR: electronic inpatient electronic record; ATDPS: automated tablet dispensing and packaging system;
eMAS: electronic medication administration system; iMAR: inpatient medication administration record.
Source: National University Hospital, Tan Tock Seng Hospital, Integrated Health Information System Pte Ltd (IHiS): Closed Loop
Inpatient Medication Management System. Slide presentation. Singapore: National University Health System, 2010. Reprinted with
permission.
Defined: CPOE
Computerized provider order
The Joint Commission’s National Patient these overarching goals and the related medi- entry (CPOE) is a software ap-
Safety Goals (NPSGs), Joint Commission cation management standards to guide their plication that enables providers
International’s (JCI) Patient Safety Goals development of a comprehensive medication to enter structured and legible
(IPSGs), the Joint Commission Medication safety plan that includes specific guidelines for patient care orders electroni-
cally within a networked hospital
Management standards, and the JCI Medi- each component of the closed-loop point-of-
information system.
cation Management and Use standards all care medication management systems. CPOE
address the importance of organizational systems are the foundation of closed-loop,
culture, effective communication, and meticu- point-of-care medication management sys-
lous medication management systems. Some tems and are addressed here first.
standards broach the entire medication admin-
istration process, such as NPSG 3, which Prescribing
addresses medication safety, and IPSG 3, CPOE systems allow the nurse to clearly read
which addresses improving the safety of high- the medication orders, as well as the name
alert medications. Each organization can use of the prescriber, decreasing the chances of
43
TABLE 2-1. Properties of Basic and Advanced Clinical Decision Support

Systems (CDSSs)
Basic CDSS Advanced CDSS

User can select form, dosage, duration, and frequency Dosing guidance based on age, renal function,
from lists. pregnancy, indication, additive toxicity, and drug use
restrictions
Prescription output complies with Joint Commission Drug-problem list or drug–diagnosis interaction (con-
requirements for drug labeling and use of abbrevia- traindication) alerts triggered by a prescription order
tions.
Alerts for drug allergies and drug–drug interactions Drug–lab result interaction alerts triggered by a new
lab result, first-time prescription order, refill orders, or
change in prescription orders.
Supports (but does not require) entering an indication Proactive alerts for errors of omission, indicating
for the prescription medications needed for preventive care and based on
disease management guidelines
Defined: CDSS
Similar to CPOE, e-prescribing When a drug is prescribed, the system links to general Alerts for formulary warnings specific to the patient’s
can include clinical decision prescribing information that is not patient specific, insurance
support systems (CDSSs) to help including contraindications, adverse effects, and dose
prescribers make safer choices adjustments for age, weight, or lab results.
when prescribing medications.
Patient instructions for using the medication are Language/culture-specific patient information
CDSSs with e-prescribing vary
provided at the appropriate literacy level.
between basic and advanced
versions. Links to general formulary reference information Drug reference that is indexed to provide specific
answers to likely questions (such as Can this drug be
used during pregnancy?)
Weight-based dosing for prescriptions for pediatric
patients
Notification when renewals are due or if patients do
not fill their prescriptions in a timely manner
Drug appropriateness checking based on documented
problems (such as for look-alike/sound-alike
medications)
Alerts for drug–food allergy interactions
Suggestions for consequent orders and tests; also
displays schedule of future monitoring events (for
example, Check drug levels every x months.) with
timely reminders
High-specificity therapeutic duplication alerts
Source: Teich J.M., et al.: Clinical decision support in electronic prescribing: Recommendations and an action plan: Report of the
joint clinical decision support workgroup. J Am Med Inform Assoc 12:365–376, Jul.–Aug. 2005.
44
misreading the order and eliminating the need CDSSs, CPOE, and EHRs. The 2003
for phone calls to decipher illegible hand- Medicare Modernization Act (MMA) began
writing. Prescription and transcription errors to foster outpatient electronic prescribing in
account for approximately half of all ADEs in January 2006 in an attempt to improve patient
the hospital setting,36 and a landmark early outcomes and patient care costs.39 Pre-
study found that 56% of preventable ADEs scription errors are further decreased when
occur during prescription alone.37 Inpatient CPOE systems are linked with advanced
transcription errors are not completely elimi- CDSSs and electronic health records (EHRs).
Advanced CPOE systems with CDSSs have Defined: EHR
nated with this basic technology unless the
Electronic health records (EHRs)
medication order is transmitted to an eMAR. been shown to decrease potential ADEs by
document patient demograph-
86%.40 To decrease potential ADEs in the out- ics, progress notes, nursing
CDSSs and CPOEs. In a review of medica- patient population, Gandhi et al. documented notes, problems, medications,
tion-related clinical decision support systems the need for advanced electronic prescribing vital signs, medical history,
(CDSSs) in CPOE, Kuperman et al. found that systems with CDSSs.41 Automated ADE alerts immunizations, laboratory data,
these systems can improve patient safety and and other customized trigger alerts that are and radiology reports. This infor-
linked to key words or phrases in the CPOE mation is documented during one
lower medication-related costs.38 Kuperman et
or over several visits to the same
al.’s recommendations address the importance system and the EHR are powerful technologi-
organization. Although EHRs
of technology decisions for success of CPOE cal tools to actively monitor the safety and
may list the current medications
and CDSSs and that health care organizations efficacy of medication management systems. a patient has been prescribed,
implementing CPOE can support the CDSSs they do not document whether
that they implement, ensure that clinical knowl- Nursing feedback about clinical practice is the medications have actually
edge underlying the CDSSs is reasonable, and essential to design and implement CDSSs been given.42
appropriately represent electronic patient data. and CPOE systems that are meaningful and
They recommend that a medication-related support the nursing work flow. Nursing infor-
CDSS is probably best introduced into health matics specialists and staff nurses should be
care organizations in two stages—basic and consulted to create and customize the user
advanced. A basic CDSS includes drug-allergy interface for these systems to increase their
checking, basic dosing guidance, LASA drug utilization. When the user interface is mean-
alerts, formulary decision support, duplicate ingful to the nurse, it becomes easy to follow
therapy checking, and drug–drug interaction intended procedures and decrease the occur-
checking.38 An advanced CDSS includes dos- rence of workarounds.
ing support for high-risk patients (for example,
renal insufficiency, geriatric), guidance for After the system is linked with the patient’s
medication-related laboratory testing, drug– EHR, information can include allergies, weight-
pregnancy checking, clinical protocols and based dosing, and other patient-specific
medication order templates, and drug–disease prescribing contraindications. Electronic pre-
contraindication checking.38 (See Table 2-1 on scriptions from the outpatient community set-
page 44.) Among the challenges addressed ting can be archived in data warehouses that
are the need for a team approach to develop- will allow providers greater access to pread-
ing, implementing, and evaluating CDSSs and mission medication information throughout
CPOE systems and also the need for gathering the continuum of care.43 This technology pro-
expertise from within health care organizations, vides all clinicians—including nurses—with a
application and knowledge-base vendors, poli- specific method for addressing the NPSG that
cymakers, and researchers. requires accurate and complete medication
45
TABLE 2-2. Impacts of Computerized Provider Order Entry (CPOE) Systems
Positive Impact Areas of Concern

Eliminates errors due to poor or illegible handwriting Increases volume of medication orders
Clearly identifies prescribers Can be difficult to use in emergency situations
Provides basic drug-allergy screening at time of Can be too easy to use, allowing clinicians to create
provider order entry group orders without individual review
Stimulus for HIT
Provides basic drug–drug, drug–food, drug–lab test Increases nurse expectations for medication avail-
The Health Information Technol-
interaction screening at time of provider order entry ability
ogy for Economic and Clinical
Health (HITECH) act within Dramatically speeds up availability of orders Requires more time for structured approach
the 2009 American Recovery Provides access to enter orders from any computer Requires contingencies during network downtime
and Reinvestment Act (ARRA) terminal
provides $20 billion for health Limits/restricts access to prescribe drugs or drug Must allow for system slowness
information technologies (HITs) classes to selected providers (for example, chemo-
to support the creation and ex- therapy)
pansion of EHRs and penalizes
Provides templates to ensure that all critical ele- Requires accessibility to computers and printers
providers and health care institu-
ments of an order are entered
tions that do not utilize electronic
solutions by 2015.45 Links directly to other clinical systems Tends to minimize face-to-face contact with provid-
ers
Provides opportunity to program in specific medica- May promote alert dependence (may condition staff
tion use interventions to react only when the computer alerts them)
Provides opportunity to use standardized order sets May contribute to alert fatigue
and pathways
reconciliation across the continuum of care. Effective health information technologies

CPOE systems that include an electronic (HITs) provide mechanisms for seamless and
medication reconciliation feature can also consistent communication across all phases
reduce errors at the transitions of care.44 See of the patient’s health care continuum via the
Table 2-2 above for a comparison of the posi- EHR. The CDSS in the EHR ideally provides
tive and negative impacts of CPOE systems. current drug references, dosing guidelines,
dilution guidelines, and hospital policies and
EHRs also have the potential to support the procedures regarding medication adminis-
nurse’s medication administration practice. tration that are easy to find, require minimal
Studies have indicated that many ADEs are computer screens for access, and contain con-
due to a lack of knowledge about the drug or sistent information. The significant increase
the patient at the point of care.5 Nurses may in the numbers of drugs administered, the
not have ready access to drug and patient current U.S. drug shortages, and the rapidly
data sources due to geography, shift, and clini- changing pace at which new drugs are devel-
cal specialty. Critical medication management oped mandate the need for these resources.
decisions by nurses at the point of care require Providing these resources at the point of care
easy access to multiple sources of patient and increases the likelihood that the nurse will
clinical data that can be found in a networked access the information and administer the drug
information system. safely (within requisite dosing and monitoring
46
parameters). Thus, although the best evi- medications that are ordered and approved for
dence regarding the benefits of CDSSs has specific patients.
been reported with respect to CPOE, CDSSs
are found throughout the entire medication Requiring pharmacy verification or approval of
management process, including those parts of medications prior to allowing access to them
the process involving EHRs. provides another layer of safety, but it may
also cause delays in care while nurses wait for
Dispensing approval. And any delay in retrieving medica-
The second element of a closed-loop medi- tions during an emergency could have devas-
cation management system is the pharmacy tating consequences. This potential problem
information system (PIS) that links the CPOE can be avoided by allowing nurses to override
application to the dispensing device at the the ADM’s security features under specific cir-
point of care. The PIS provides a mode for cumstances, keeping in mind that overrides
pharmacy experts to further analyze medica- will result in losing the benefits of pharmacy
tion orders prior to dispensing medications review. An interdisciplinary drug safety group
to the point of care and to communicate this should closely monitor the override feature to
information to nurses. Similar to CPOE appli- ensure that it is always used appropriately.
Defined: BCMA
cations, the greatest benefits are realized Bar code medication admin-
when the PIS is linked to CDSSs and an EHR. The ADM should also be monitored for human istration (BCMA) requires a
After the pharmacist has verified the safety errors in stocking and retrieval, as well as for nurse to scan a bar code on
and appropriateness of each medication order, system faults that can lead to retrieval errors. the patient’s identification band
current recommendations include using bar For example, the ADM should prevent the (which is generally attached to
coding technology for accurately dispensing storing of LASA drugs in the same bins. Newer the patient’s wrist) to identify the
patient and then scan the bar
medication. Bar code scanning was shown to ADM designs alert the user with an auditory
code on medications packaged
decrease dispensing errors by 85% in a study alarm if the wrong bins are opened. Regard-
in unit-dose form (some systems
in which medication bar codes were scanned in less of any such technological features, will also scan bar codes on
the pharmacy and then again during stocking nurses need to continue to check the products blood products before they are
on the nursing units.46 Medications were either that they select because stocking errors by administered) to ensure correct
stocked into automated dispensing machines pharmacy staff can occur.46 matching of medications to pa-
(ADMs) or at alternative sites that accommo- tients. BCMA (in conjunction with
the eMAR) will identify potential
dated unique storage requirements. The effec- Medication Administration
administration errors, such as
tiveness of ADMs has been enhanced through Bar coding technology decreases medication
wrong time, incorrect dose, or
the use of carousel dispensing technology, errors by supporting the five rights of medi- wrong route, and require the
drug-dispensing robots, and bar code–repack- cation administration through more accurate nurse to resolve the discrepancy
aging centers that all leverage the use of bar dispensing (as described above) and through prior to administration.
code technology.44,45,47,48 an improved medication administration pro-
cess.32,46,49,50 A recent Japanese study by
Nurses and ADMs. Nurses began using Akiyama et al., in collaboration with the Mas-
ADM technology in the 1980s as a convenient sachusetts Institute of Technology, examined
method for storing and accessing medica- a bar code medication administration (BCMA)
tion at the point of care as well as for tracking system that used a personal digital assistant
medication use. Systems that require a unique (PDA) to capture data. The researchers found
password identifier or fingerprint biometric that the system was effective in preventing
authentication to access the ADM can also medication errors at the point of care and that,
be used to document access to the medica- by analyzing the captured data, the hospital
tions. When the ADM is linked to the PIS and was able to improve patient safety.50
CPOE, access can be further limited to those
47
BCMA. Foote and Coleman51 identified the unable to access medication administra-
five goals of the BCMA system as increasing tion information due to software constraints
patient safety, increasing patient satisfaction, and limitations in the number of available
increasing efficiency, increasing nursing satis- computers. Members of both disciplines
faction, and decreasing patient care costs. need access to adequate numbers of
devices when making patient rounds so that
BCMA systems involve a series of scans that accurate real-time data are readily acces-
accomplish the following 20,49: sible to all clinicians to review medication
• Link a medication with the CPOE system profiles. Valuable time for direct patient
• Verify the five rights care is lost when nurses wait for devices/
• Document the complete details of the consoles/terminals to become available.
DEFINED: eMAR
administration in an eMAR However, other researchers have shown
Electronic medication admin-
istration records (eMARs) are • Provide detailed reports that nurses can that nurse–pharmacist communication
often integrated into an EHR and use to identify opportunities for improve- may improve upon adoption of BCMA and
allow nurses and other health ments in the system decentralized pharmacy support systems.32
care providers to document the 3. Nurses may circumvent the system during
medications administered at the times of high workload by eliminating
Unintended consequences of BCMA. Like
point of care. With an eMAR, critical safety checks, such as scanning
other technologies, if a BCMA system is not
nurses always have access to
designed properly, new errors may be created a patient’s identification bracelet. These
the patient’s up-to-date list of
through its use. A post–BCMA implementation workarounds may occur when the nurse
medications, with corrections
added in real time, and they study conducted by Patterson et al. at three is unable to complete the intended task26
are able to focus solely on the Veterans Health Administration hospitals iden- or when there is a user’s resistance to
medications due within the next tified five negative, unintended outcomes as a change. For example, at Brigham and
hour. Furthermore, eMARs can result of implementing BCMA.52 These were Woman’s Hospital some nurses were scan-
require nurses to enter vital sign ning alternative bracelets that were not on
later supported by the technology evaluation
information before administering the patient because they perceived this to
performed by Koppel et al.19
a medication to assess whether
1. Software designs that remove medica- be more efficient. At Brigham and Women’s
the medication should be held
based on the preset parameters. tions from the eMAR when medications Hospital, multiple identification bracelets
Finally, the eMAR can provide are overdue or when there are automated are sent to the patient care unit to facilitate
organization leadership with stop orders create the potential for medica- typical patient care needs; however, only
safety reports on medications tion administrations to be missed. Systems one bracelet is active in the system at any
administered late or omitted need to be designed so that they provide time. When a user attempts to scan a brace-
altogether, as well as informa- let at another location, the first bracelet is
appropriate cues and prompts for the
tion on the volume of high-alert
nurse when any automated deletion action automatically deactivated and a warning is
medications being prescribed
occurs. Koppel et al. describe multiple displayed indicating the time and date, as
and administered.53
technology workarounds related to subop- well as the user who deactivated the brace-
timal software design, including omission let. This allows the user to investigate the
of process steps, out-of-sequence process duplicate scans to avoid patient misidenti-
steps, and unauthorized process steps.19 fication, and the scan is also tracked in a
The research also revealed a variety of central report for human factors surveil-
potential factors that lead to this bypass of lance. Further research from Japan has
safety systems, including issues that were demonstrated that it is not just the heavy
technology related, task related, organiza- workload in a hectic health care environ-
tional, patient related, and environmental.19 ment but the volume of diverse tasks and
2. Communication between physicians and the resulting vulnerability to distraction that
nurses regarding patients’ medication can lead to medication errors.50
management degraded. Physicians were
48
4. BCMA also places a heightened emphasis on the pharmacy’s restocking of medications in

the timeliness of administering medications. the unit-based ADMs based on actual medica-
Nurses prioritize timely medication adminis- tion use. This will avoid the need for the nurse
tration above other more important activities to make multiple phone calls to the pharmacy
for fear of disciplinary repercussions. During and will prevent delays in care to patients.
the initial implementation of BCMA, when Keohane et al. performed a BCMA time-motion
users are first learning, they should be study at a major U.S. teaching hospital in the
encouraged to keep their care centered on Northeast that revealed no increase in the
the patient and not the computer. Defini- amount of time required for medication admin-
tions of timely medication administration istration while using a well-designed BCMA
may need to be expanded, as, for example, system that includes the features described
with the recent controversy regarding the previously.9 The study also documented that a
30-minute rule from the Centers for Medicare closed-loop medication administration system
& Medicaid Services (CMS) and the result- that uses bar code technology can minimize
ing recommendations from the Institute for time spent on inefficient activities, thus allow-
Safe Medication Practices (ISMP) regarding more time for direct patient care.
ing scheduled, time-critical scheduled, and
non-time-critical medications. These ISMP See Sidebar 2-1 on page 50 for a list of the
recommendations were based on a national, hardware considerations involved in integrat-
online nursing survey and illustrate the power ing a BCMA system.
of the voice of nursing.
5. After the implementation of BCMA, nurses Smart infusion pumps. Integrating smart or
demonstrated decreased ability to deviate intelligent infusion pumps into a closed-loop,
Smart Infusion Pumps
from routine sequences.52 This outcome point-of-care medication administration sys-
Smart infusion pumps are intra-
illustrates that users will bypass critical tem can also increase medication adminis- venous infusion devices that can
safety procedures when the system is not tration safety when this technology is used do the following:
flexible enough to accommodate all clinical effectively in the context of a culture of compe- • Use dose calculation soft-
situations. Staff nurse consultation regard- tence and safety. The goals for effective use ware with upper and lower
ing the range of clinical situations and of these pumps should include the following: dose limits for intravenous
infusions via large-volume,
nursing practices is essential. • Direct communication to CPOE systems to
syringe, and patient-
prevent errors within normal dose range
controlled analgesia pump
Time involved in using BCMA. Nurses also • Integration with real-time clinical data technology
voice concerns about the amount of time to promote monitoring and critical • Continuously display medica-
required to use a BCMA system. The actual interventions tion name, dose, and infusion
steps of medication administration may take • Multidisciplinary drug library creation and rate
more time, but it is important to note the maintenance that complement the practice • Provide alerts for the nurse
amount of time saved in other phases of the of all users when dosing limits are
exceeded
complete medication administration process. • Connection to a complementary wireless
• Archive useful quality data
Transmitting medication orders to an eMAR technology that affords timely, intuitive
regarding drug library usage,
eliminates the need for transcription, along library edits and acquisition of continuous bedside infusion program-
with the errors that often occur with manual quality data for optimization of use of the ming, and error prevention
transcription. And eMARs that specify the dis- smart pump
pensing location on a unit will save time locat-
ing medications, as well as reduce the time More work is required to reach these goals,
spent on unnecessary phone conversations and expert nurses must partner with vendors
with pharmacy staff. A BCMA system that is of smart infusion pumps to design and imple-
bidirectionally linked to the PIS will facilitate ment the right technology.
49
SIDEBAR 2-1. Bar Code Medication Administration (BCMA) Hardware

Considerations
• Wireless Network ◦ Mounted v. mobile

◦ Security (WPA, WPA2) ◦ Infection control considerations
◦ Interference with other medical equipment ◦ Durability—spills, drops
◦ HIPAA (Health Insurance Portability and Ac- • Patient ID Bracelets
countability Act of 1996) ◦ Cost
◦ Availability ◦ Durability
• Bar Code Selection: Linear v. 2D ◦ Accommodation of multiple bar code formats
• Bar Code Scanner Selection:Tethered v. wire- ◦ All patient populations
less, ability to read multiple bar codes • Smart/Intelligent Infusion IV Pumps
• Computer ◦ Robust drug library
◦ Wired v. wireless ◦ Wireless communication
◦ Handheld, tablet, laptop, desktop ◦ Automated pump programming
The quality data also archive the type of safety Dosing limits and smart infusion pumps.
alerts triggered during near-miss events and The interdisciplinary team must carefully and
illustrate user behaviors when a safety alert is thoughtfully discuss critical decisions regarding
encountered. These data should guide the clini- the ability to override drug-dosing limits by the
cians responsible for drug library maintenance nurse. Two types of dosing limits are commonly
in perfecting entries to better accommodate the found in smart infusion pumps. A soft limit will
dynamic requirements of modern medication allow the nurse to override the alert and pro-
management practice. Connecting smart infu- ceed with the medication administration, and
sion pumps via wireless networks does pose a hard limit will force the nurse to either repro-
some challenges within the United States, with gram the device or cancel the infusion. Effective
potential U.S. Food and Drug Administration dosing limits allow dosing flexibility to address
(FDA) regulations that may define the wireless unique patient situations while avoiding com-
network connecting the information technology mon user interface errors. The pump’s quality
with a medical device as a medical device itself. data will reveal a variety of graphic user inter-
This distinction will subject the wireless network face errors, including extra and missing zeros,
to stringent FDA medical device standards. missing decimal points, decimal points in an
incorrect sequence, and transposing infusion
Drug libraries and smart infusion pumps. rate and dose. It is common to find users enter-
Medication administration limits are defined ing infusion rates in the dose field during the
in a drug library that is created on a separate transition from a rate-controlled infusion device
computer and uploaded to the programming to a dose-controlled infusion device.
module of the infusion pump. The drug library
needs to be created by an interdisciplinary Managing infusion pump risks. Calibration
team of experts, including physicians, nurses, errors using IV infusion pumps are a lead-
and pharmacists, that is supported by the insti- ing cause of ADEs during the administration
tution’s biomedical engineers and information phase of medication management.54 Smart
services. Drug libraries containing information/ infusion pump technology will decrease the
parameters that do not reflect current medica- risk by assisting with drug recognition, mathe-
tion administration practices have been shown matical conversion of dose rate units into fluid
to be ineffective.9 flow units, keypad data entry, and support of
50
fundamental institutional medication manage- implementation team must create a manual

ment protocols. system that can efficiently and effectively
duplicate the electronic process. At Brigham
To effectively manage this risk, multiple factors and Women’s Hospital, a fail-safe computer
must coexist in the institution. Smart infusion is identified on every patient care unit, and
pump technology must be consistent through- it functions as the memory of the medica-
out the facility to avoid confusion regarding tion management system. When computer
use of the hardware, software, and associated systems fail, this computer is able to print
disposable products. IV admixture concentra- hard copies of existing provider orders, cur-
tions, dosing units, drug nomenclature, and rent medication administration records, blank
the procedure for administering medications medication administration records, and the
not in the drug library must be standardized previous 48 hours of medication administra-
and compatible with all elements of the closed- tion history. Each failure management system
loop, point-of-care medication management will need to be customized to the needs of the
system (for example, CPOE, PIS, eMAR) and individual institution.
institutional resources and reference texts.
Human Factors Engineering

Innovative medication safety technologies Each interdisciplinary
have made incremental improvements in implementation
patient safety. To achieve the full potential of team must create a
current and future technologies, more atten- manual system that
tion must be focused on the human interface. can efficiently and
Human beings will make predictable errors. effectively duplicate the
The common work-around archetypes (noted electronic process.
in the previously discussed research by Kop-
pel and colleagues) are all explained in the
human factors engineering (HFE) literature.15
HFE principles can provide the theoretical
framework for the redesign of medication
Nurses’ Perceptions, Critical
safety systems that will raise the use of medi- Thinking, and Satisfaction with
cation safety technologies to their full potential, Technology
thereby truly making it easy for the practitio-
ners to provide safe patient care. (For more Several recent studies have addressed key
information on human factors and human fac- areas of nurses’ perceptions, critical think-
tors engineering, see Chapter 1.) ing, and satisfaction with technology to
improve medication safety.33,54–56 Gouveia57
Failure Management Systems also addressed satisfaction of pharmacists
and evolving issues for the future of patient-
All features of medication management prac- centered care. Eisenhauer et al.58 found that
tice technology are limited by access to com- nurses’ reported thinking during medication
puter systems. Creating a comprehensive administration included10 specific categories:
failure management system is a critical ele- communication, dose time, checking, assess-
ment of medication management practice. ment, evaluation, teaching, side effects, work-
This process is separate from the FMEA used arounds, anticipated problem solving, and
to identify the unintended consequences of drug administration. The researchers’ content
technology integration. Each interdisciplinary analysis revealed that safe administration of
51
medications in a technology-enhanced envi- technology.33 The study respondents also

ronment was more than a technical mechani- indicated that medication errors were under-
cal process, but was an active use of critical reported; thus, this remains an important area
thinking and clinical judgment. for further education and research.
Nurses’ Critical Thinking in Technology Conclusion

Application
Within this technology-enhanced medication In this chapter, we have explored the twenty-
administration system, nurses’ critical thinking first-century nursing environment relative to
focused on five key areas58: technology and medication administration.
1. Direct patient observation and data interpre- Among the challenges are the complex issues
tation pre- and postmedication administration of linking medication administration and other
2. Interpretation of patient data and applica- parts of the medication management process
tion of clinical knowledge with each patient with effective use of well-designed technolo-
situation gies. Using technology for medication man-
3. Anticipatory problem solving in relation to a agement should limit errors and improve care
patient’s clinical trajectory across settings. However, major challenges
4. Interdisciplinary consultation with other exist in linking technologies electronically with
nurses and pharmacists documentation systems and seeking the opti-
5. Communication with physicians for data veri- mal solution for each unique clinical setting.
fication, patient advocacy, and prevention of See Sidebar 2-2 on page 33 for a list of the
medication errors and adverse drug events lessons on technology integration learned by
our team at Brigham and Women’s Hospital.
Nurses’ Satisfaction with Technology
Hurley et al. assessed the satisfaction of Future Advancements in Health Care
nurses with medication administration pre- Technology
and postintroduction of BCMA/eMAR.59 In The future nursing work environment is likely
their study, scores on efficacy, safety, and to experience enormous changes during the
access were significantly higher postintro- next decades. Kelly and Rucker suggest five
duction of technology-enhanced medication advancements that may enhance patient
administration, and scores on the Medication safety and further transform health care and
Administration System–Nurses Assessment technology24:
of Satisfaction (MAS-NAS) scale were also 1. Development of a national, coordinated
significantly higher after conversion to BCMA/ health information network based on a
eMAR.59 Fowler et al.56 also utilized the MAS- longitudinal EHR and central storage of
NAS scale in their longitudinal study of nurses’ health records
satisfaction and reduction in medication 2. Creation of a national center for patient
errors. Nurses reported that the BCMA system safety (suggested by the Institute of Medi-
was safer than the previous system, based on cine) instituted and patterned after the
nurses’ self-report of increased satisfaction National Transportation Safety Board with
related to the ease of checking the five rights initiatives similar to the Institute for Health-
of medication administration. The lowest area care Improvement57 and the Canadian
of satisfaction was found in ability to retrieve Patient Safety Institute8
“stat” medications. In a study by Ulanimo et al., 3. Establishment of satisfactory measure-
nurses indicated that information technology ments of global safety that assess
decreased medication errors; however, these improvements
errors still occurred despite sophisticated
52
SIDEBAR 2-2. Technology Implementation Lessons Learned at Brigham and

Women’s Hospital
• Thorough and inclusive work flow analysis is essential. Investigate current practice deviations to define
electronic solutions.
• Technology implementation drives many practice changes for all disciplines.
• End users must be intimately involved in hardware/software design, implementation, and maintenance.
• Staff change champions and resistant adopters should be recruited early in the process.
• Training should incorporate simulated clinical scenarios using the actual software and hardware that staff
will use on in their settings. Careful planning and budgeting are necessary to facilitate this critical element of
technology implementation.
• Budget for clinical nurses to spend time as real-time resources/trainers/coaches without being counted in
the regular staffing contingent—preferably during early adoption.
• Use clinicians as coaches/trainers to explain the application of the technology within their own disciplines’
work flow.
• Technology must support best practice (“Make it easy to do the right thing.”)
• Real-time feedback and response to concerns are essential for sustainability.
4. Development of incentives for hospitals to administration. As Scanlon and Karsh describe

improve safety it, the science of human factors and HFE may
5. Formation of a cadre of health care be the key to achieving a safe medication
students educated for the growing older environment. Included among these human
population who will need health care in a errors are memory limitations, variable/imper-
rapidly changing, technologically advanced fect compliance with safety rules, misuses or
environment resistance to technology, and general less-
than-perfect reliability and accuracy of actions
Future technological advances are likely to and decisions.18
include handheld computers, ready avail-
ability of personal digital assistants (PDAs), Scanlon and Karsh also describe the impor-
and paperless health care systems. It is pos- tance of improved teamwork and team perfor-
sible that radiofrequency identification (RFID), mance.18 High-performing teams are those that
rather than bar coding technology, may also be have a shared mental model of what needs to
used for patient and staff identification, track- be accomplished, share the team mission, and
ing, and other applications in the future health understand each others’ roles and expecta-
care environment.26 The exponential growth tions. As the science of technology-enhanced
in technology will likely transform our health medication management continues to develop,
care system and the work of nursing during the these elements of teamwork must be fully inte-
next decades. For this growth in technology to grated in the health care organization.
make a meaningful impact on patient safety,
our community needs to analyze our experi- Collaborations across health care organization
ence to date and utilize HFE principles to cre- networks and systems—including patient billing
ate effective mitigation of medication errors. systems—should also be a goal in implement-
ing technology to enhance medication safety.60
In the future, a utopia may be reached as sci- Danello et al. found a high return on investment
entific and technological advances will limit in their financial analysis of the incremental
the possibility of human error in medication costs of IV safety systems.61 Financial reasons
53
for engaging in technology enhancements may safety and employee well-being: A study of
limit the rising health care costs. workload in pediatric hospital pharmacies. Res
Social Adm Pharm 6:293–306, Dec. 2010.
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34. Hendrich A., Chow M.P., Goshert W.S.: A pharmacy. Ann Intern Med 145:426–434, Sep.
proclamation for change: Transforming the 19, 2006.
hospital patient care environment. J Nurs Adm 47. Temple J., Ludwig B.: Implementation and
39:266–275, Jun. 2009. evaluation of carousel dispensing technology
35. Asian Hospital Management Awards Steer- in a university medical center pharmacy. Am J
ing Committee: Asian Hospital Management Health Syst Pharm 67:821–829, May 15, 2010.
55
48. Cina J., et al.: Medication errors in a pharmacy- 2007.

based bar-code-repackaging center. Am J Health 56. Fowler S.B., Sohler P., Zarillo D.F.: Bar-code
Syst Pharm 63:165–168, Jan. 15, 2006. technology for medication administration:
49. Poon E.G., et al.: Effect of bar-code technology Medication errors and nurse satisfaction.
on the safety of medication administration. Medsurg Nurs 18:103–109, Mar.–Apr. 2009.
N Engl J Med 362:1698–1707, May 6, 2010. 57. Gouveia W.A.: Pharmacy as a patient-centered
50. Akiyama M., Koshio A., Kaihotsu N.: Analy- practice: Reflections from center stage. Am J
sis of data captured by barcode medication Health Syst Pharm 66:449, Mar. 1, 2009.
administration system using a PDA; aiming at 58. Eisenhauer L.A., Hurley A.C., Dolan N.:
reducing medication errors at point of care in Nurses’ reported thinking during medication
Japanese Red Cross Kochi Hospital. Stud Health administration. J Nurs Scholarsh 39:82–87, Mar.
Technol Inform 160(pt. 1):774–778, 2010. 2007.
51. Foote S.O., Coleman J.R.: Medication 59. Hurley A.C., et al.: The Medication Administra-
administration: The implementation process tion System—Nurses Assessment of Satisfaction
of bar-coding for medication administration to (MAS-NAS) scale. J Nurs Scholarsh 38:298–300,
enhance medication safety. Nurs Econ 26:207– Sep. 2006.
210, May–Jun. 2008. 60. Wakefield D.S., et al.: A network collabora-
52. Patterson E.S., Cook R.I., Render M.L.: tion implementing technology to improve
Improving patient safety by identifying side medication dispensing and administration in
effects from introducing bar coding in medica- critical access hospitals. J Am Med Inform Assoc
tion administration. J Am Med Inform Assoc 17:584–587, Sep.–Oct. 2010.
9:540–553, Sep.–Oct. 2002. 61. Danello S.H., et al: Intravenous infusion safety
53. Scott-Cawiezell J., et al.: Medication safety technology: Return on investment. Hosp Pharm
teams’ guided implementation of electronic 44:680–688, Aug. 2009.
medication administration records in five
nursing homes. Jt Comm J Qual Patient Saf
35:29–35, Jan. 2009.
54. Rothschild J.M., et al: A controlled trial of
smart infusion pumps to improve medication
safety in critically ill patients. Crit Care Med
33:533–540, Mar. 2005.
55. Hurley A.C., et al.: Nurses’ satisfaction with
medication administration point-of-care
technology. J Nurs Adm 37:343–349, Jul.–Aug.
56
FOCUS: Technology
FOCUS
Technology:
Benefits of Telemonitoring in Home Care
Telemedicine is the exchange of health care information from one site to another via electronic
communications to improve patient care. Telemonitoring is a type of telemedicine in which
the care recipient and caregiver are at a distance from each other. Telemonitoring is particularly
appropriate for home care. In home care, telemonitoring allows patients to take their own
blood pressure, pulse, oxygen level, weight, temperature, blood glucose, and other significant
measurements in the comfort of their home via an easy-to-use medical device. The informa-
tion is transmitted electronically via phone lines to the home care organization, where it is
reviewed by nurses and physicians. As a result of the reported patient information, home care
organizations can make telephone calls or home visits to clarify the information and provide
patient education. This technology has traditionally been used for patients with chronic dis-
eases, such as congestive heart failure and diabetes mellitus, but can be expanded to all home
care patients.1 It can also be applied to rural areas to reduce the amount of traveling done by
home care nurses to provide health care services.2
Telemonitoring may be used in hospice and other health care settings as well. It not only offers
improved care for patients but also may provide significant cost savings for national health
care systems. A number of evaluation studies suggest that this technology improves control of
chronic diseases, increases adherence to medication regimens, reduces the number of hospital-
izations and emergency department (ED) visits, decreases hospital length of stay, and lowers
overall health care costs.1,2
Benefits of Monitoring Chronic Disease: Research Findings

To illustrate the benefits of telemonitoring for patients with chronic diseases, a randomized
controlled trial of Veterans Health Administration patients with poorly controlled diabetes
mellitus (and a glycosylated hemoglobin [HgA1c] ≥ 7.5%) compared telemonitoring and
active medication management by an advanced practice nurse with monthly care coordination
via telephone calls by a diabetes educator.1 Patients in the telemonitoring group had four times
more nurse-to-patient telephone contact time and demonstrated greater decreases in their
HgA1c at both three months (1.7% versus 0.7%) and six months (1.7% and 0.8%).1 A large
study of Pennsylvania patients with congestive heart failure who received home care services
found that 10.1% of patients in traditional home care were hospitalized as opposed to 6.2% of
those using telemonitoring.2 Furthermore, only 4.5% of the patients who used telemonitoring
required ED visits as compared with 8.8% of traditional home care patients.2
Preventing Hospitalizations with Daily Telemonitoring: Case Study

BayCare Home Health, Dunedin, Florida, uses telemonitoring devices with its patients to
monitor daily vital signs, weight, and any other pertinent information based on patients’ back-
grounds. BayCare has seen improvements in patients’ adherence to medication regimens, fewer
57
FOCUS
Technology:
Benefits of Telemonitoring in Home Care (continued)
hospital admissions, and shorter lengths of stay when patients are admitted to the hospital.2
Because telemonitoring allows for daily monitoring of patients’ vital signs, health care provid-
ers can identify and address problems before they trigger hospitalization. For example, data
reported through telemonitoring can help health care providers identify patients who are not
taking their medications correctly, enabling providers to intervene appropriately with custom-
ized education.
Cost Savings with Telemonitoring

Telemonitoring is a cost-saving technology because it prevents costly hospital admissions and
ED visits. For example, researchers at Pennsylvania State University estimated that the costs for
home care patients who were admitted to the hospital were $87,327 for those with telemoni-
toring services compared with $232,873 for those without telemonitoring services.2 And Kai-
ser Permanente found that costs for patients using telemedicine services were $1,948 compared
with $2,674 (including ED visits and hospital admission) for patients receiving traditional
home care services.2 Patients also save time and money with telemedicine because they don’t
have to make frequent visits to a physician’s office or hospital for health care services.2
References
1. Stone R.A., et al.: Active care management supported by home telemonitoring in veterans with Type 2
diabetes: The DiaTel randomized controlled trial. Diabetes Care 33:478–484, Mar. 2010.
2. Konschak C., Flareau B.: New frontiers in home telemonitoring: It’s already here. Where are you?
J Healthc Inf Manag 22, Summer 2008. http://www.himss.org/content/files/Konschak.pdf (accessed Apr.
16, 2011).
58
CHAPTER THREE Medication Reconciliation:
Lessons Learned
AUTHORS: Our Lady of Lourdes Memorial Hospital in Binghamton, New York—Caryl Ann Mannino,
R.N., B.S.N., O.C.N.®, N.E.-B.C.; Anita Markovich, R.N., B.S.N., M.S.N., M.P.H., C.P.H.Q.; and
Deborah Mican, R.N., B.S.N., M.H.A., C.N.O.R.
A 75-year-old male patient presents to the emer- more errors.2 Since the Institute of Medicine
gency department (ED) and provides a handwrit- issued To Err Is Human in 1999, organizations
ten list of medications to the triage nurse. The in the United States and around the world have
patient states that he takes all of these medications recognized the importance of patient safety
at home. When the nurse proceeds to reconcile the and have identified safe medication practices
patient’s home list of medications with what was as one of the most important ways to reduce
previously entered in the electronic health record the occurrence of adverse health care events.3
(EHR), she finds additional medications ordered
by the primary physician for control of seizures. In addition to the primary concern of patient
In the process of verifying the home medications safety, there is a further incentive to solve the
with the patient, the nurse is called away to care problems associated with medication inaccu-
for an emergent patient. The nurse returns to the racies—financial cost. It is estimated that 14
original patient, indicates in the EHR that the cents of every dollar go toward prescription
ө
home medication list is complete—even though the medications, and the increase in that cost (up
anticonvulsant medications have been left off. The 89% from 2000 to 20074) has received consid-
physician orders admission medications from the erable public attention. The majority of health
list in the EHR, and the patient is admitted to care consumers are fully aware of the cost of
an inpatient unit. He never receives medications their medications. The challenges arise when
to control seizures. During the night the patient patients, unable to afford their prescribed
experiences severe seizures attributable to the error medications, present to a hospital for care
in medication reconciliation. and provide incomplete information regard-
ing medication usage—information that often
Medications are an important and integral does not reconcile with data provided by phy-
component of health care, with more than sicians and other health care professionals.
10,000 prescription medications and more
than 300,000 over-the-counter medications This chapter will present information help-
on the market in the United States alone.1 The ful to nurses in the creation and practice of a
high volume of available medications makes successful medication reconciliation program.
their potential misuse not only possible, but Much of the information was gleaned from les-
probable. The potential and actual risk of sons learned through the medication reconcilia-
errors from misuse of medications are well tion program developed at Our Lady of Lourdes
documented.1 Memorial Hospital in Binghamton, New York.
The chapter opens with a review of goals and
And the problem is not just in the United States: standards for medication reconciliation set by
In some countries, up to 67% of patients’ pre- various organizations and agencies. It contin-
scription medication histories include one or ues with an overview of the basic processes
59
involved in medication reconciliation. Next, the reconcile the list against new medication
authors present techniques related to medica- orders on admission, and provide the patient
tion lists and other medication reconciliation or family with written information about the
practices used at Lourdes, including the need patient’s medication at discharge. A written
to implement an accountability component in document must be created that lists medica-
reconciliation programs. The chapter concludes tions the patient is taking at home, and this list
with a description of a model medication recon- must then be compared with medications the
ciliation program in the ED at Lourdes. patient is to take in the health care organiza-
tion, reconciling any differences. The impor-
Goals and Standards for tance of managing medications by the patient
is reflected in education provided when the
Medication Reconciliation
patient is discharged from the organization as
In the United States, medication reconciliation an inpatient or after an outpatient encounter.
has become an integral process for organiza- Current Joint Commission standards stipulate
tions and providers as they seek to implement that at the time of discharge from the organiza-
safe practices based on goals and standards tion, the patient or family is to be provided with
of accrediting and governing bodies. On July discharge instructions, which include informa-
20, 2004, for example, The Joint Commission tion regarding medications to be taken. It is
released the 2005 National Patient Safety then the patient’s responsibility to pass this
Goals (NPSGs), including Goal 8: “Accurately information on to the next health care provider.
and completely reconcile medications across
the continuum of care.” The goal required Another aspect of the revised NPSG.03.06.01
organizations to develop their own process for deals with patient care settings that do not pro-
documenting a complete list of the patient’s vide round-the-clock service and whose ser-
current medications upon admission and then vices involve minimum medication use. Such
to communicate that information to the next organizations now have the flexibility to define
Relevant Requirements provider of service. On January 25, 2006, the types of medication information they col-
The Joint Commission’s Provi-
The Joint Commission issued Sentinel Event lect based on the services they provide.
sion of Care, Treatment, and Ser-
Alert 35, “Using Medication Reconciliation to
vices (PC) Standard PC.04.02.01
states, “When a patient is Prevent Errors,” which included recommen- National Quality Forum’s Safe Practices
discharged or transferred, the dations based on a project completed by the In 2000 the National Quality Forum (NQF)
organization gives information Massachusetts Coalition for the Prevention of was created through funding from the Agency
about the care, treatment, and Medical Errors.5,6 In 2011 The Joint Commis- for Healthcare Research and Quality and the
services provided to the patient sion reiterated medication reconciliation in the Centers for Medicare & Medicaid Services.
to other service providers who NPSGs with a focus on the risk points of medi- Dedicated to the development of health care
will provide the patient with care,
cation reconciliation. quality measures, the NQF identified evidence-
treatment, or services.”
based safe practices that should be universally
The Joint Commission’s NPSG.03.06.01 employed in clinical settings to prevent errors
Based on feedback from the field, The Joint and harm to patients.7 These practices were
Commission revised the goal for medica- released in 2003 and updated in 2006 and
tion reconciliation, effective July 1, 2011. 2009. Consensus reports published by the NQF
NPSG.03.06.01, which reads, “Maintain and in 2009 and 2010 identified medication recon-
communicate accurate patient medication ciliation as one of these safe practices for better
information,” replaces the former Goal 8. health care, and advised all health care organi-
The major requirements are that organiza- zations to develop lists, reconcile medications,
tions make a good-faith effort to get a com- and communicate an accurate patient medica-
plete list of current medications on admission, tion list throughout the continuum of care.8
60
CHAPTER THREE: Medication Reconciliation: Lessons Learned
WHO’s Solutions for Patient Safety documented discrepancies that occur at the
International initiatives also have been evolv- time of admission.10
ing to promote patient safety and prevent med-
ication errors. During 2005 the World Health At Presentation
Organization (WHO) launched the World Alli- The medication reconciliation process begins
ance for Patient Safety and, in that same year, before prescribing or administering any medi-
designated The Joint Commission and Joint cations, except in an emergent situation. An
Commission International as the WHO Collab- accurate list of a patient’s current medica-
orating Centre for Patient Safety Solutions. An tions, including prescription, over-the-counter,
International Steering Committee consisting of herbals, dietary supplements, and investi-
patient safety experts from around the world gational medications, is created. A standard-
oversees the selection of topics and the devel- ized form (paper or electronic) may be used
opment of a defined set of “Solutions.” Among for this purpose and can be one on which a
nine Patient Safety Solutions, “Assuring Medi- provider can directly add, delete, or amend
cation Accuracy at Transitions in Care” was medication orders if the form is also able to
identified and prioritized. The “Solutions” are serve as the medication order. Current medi-
currently being implemented worldwide as part cation information may be obtained from the
of a transformation to manage patient safety.9 patient or family or by examining medications
the patient may have brought in. It can also be
In 2007 the WHO provided to all its members obtained by examining a medication card the
strategies to help ensure that health care orga- patient may have on his or her person or by
nizations everywhere put in place standard- contacting community pharmacies, but nurses
ized processes for medication reconciliation, are urged to be cautious in using these means
including all steps proposed for implemen- alone without the involvement of the patient
tation in the United States. As with the Joint or family. Although nurses play an integral
Commission requirement, these strategies role in decreasing and avoiding medication
emphasize that the processes should involve errors, the medication reconciliation process
patients and families and provide clear educa- involves all disciplines, including providers,
tion on medication reconciliation.2
To begin that education, an understanding of

the basic process of medication reconciliation Although nurses
is appropriate. play an integral role
in decreasing and
The Process of Medication avoiding medication
Reconciliation errors, the medication
reconciliation process
Medication reconciliation is a process involves all disciplines,
designed to prevent medication errors at including providers,
every patient transition point in health care pharmacists—both in
delivery by using effective communication to the organization and
incorporate knowledge of current medications in the community—
into future prescribing decisions. The process other licensed
begins with the patient’s presentation at the clinicians, and patients
site of service, when earlier errors in recon- and families.11
ciliation can be perpetuated and new ones
can arise. Case studies, for example, have
61
pharmacists—both in the organization and in Other Tools

the community—other licensed clinicians, and Other tools also may help to support accurate
patients and families.11 medication reconciliation. The use of electronic
prescribing and EHRs provides technologies
At Transfer that give professionals access to more imme-
As required by the Joint Commission’s Provi- diate and complete patient information. (For
sion of Care, Treatment, and Services (PC) more information on how technology can help
Standard PC.04.01.05, “Before the organiza- nurses ensure medication safety, see Chap-
tion discharges or transfers a patient, it informs ter 2.) In addition, pharmacists’ responsibili-
and educates the patient about his or her fol- ties in most organizations include consultative
low-up care, treatment, and services.” Accord- expertise in medication therapy management
ing to the Institute for Healthcare Improvement when patients are moving through an inpatient
(IHI), poor communication of medical informa- setting.
tion at transition points is responsible for 50%
of all medication errors in the hospital.12 Continuing Struggles
Despite years of refining processes for medi-
At Discharge cation reconciliation, organizations still strug-
To be able to provide complete instructions gle with it. Adopting medication reconciliation
for the patient, the discharging provider will practices from other organizations does not
need to compare the list of admission medica- always yield the same outcomes. Time bur-
tions to the nursing medication administration den for staff remains a challenge as well: Addi-
record (MAR) and to the physician’s discharge tional time is added at each patient encounter
orders. Medication information is then pro- to complete medication reconciliation pro-
vided to the patient with review of related cesses at points of transition and to verify a
information, such as name of the medication, patient’s complete current medication list.
identification as a generic or brand name, pur- What is essential is that all health care provid-
pose, and instructions for use and duration. ers accept responsibility and effectively com-
Patients or families need to be engaged in the municate with each other at every transition of
medication reconciliation process, particularly care and within each patient setting.
at this point. By having an understanding of
their medications, patients are more likely to Medication Reconciliation at
adhere to prescribed treatments and to par-
Lourdes Hospital
ticipate in their care both within and beyond
inpatient settings. Like all health care organizations and inde-
pendent providers throughout the continuum
During Each Outpatient Visit of care, Our Lady of Lourdes Memorial Hos-
The process of reconciling medications in an pital strives to ensure that structures and pro-
outpatient setting occurs at each visit, depend- cesses are in place to promote patient safety
ing on the scope of the care provided. The and quality care related to medications.
medication information is collected and doc-
umented in a list or other format and based Structures and dynamics of health care
on the service being provided to the patient. relationships. Most nursing services, includ-
The use of standardized, effective tools ing those at Lourdes Hospital, have devel-
may contribute to the success of medication oped a professional practice model and care
reconciliation.13 delivery system represented by the diagrams
in Figures 3-1 and 3-2 on page 64. Typically,
the center of such schematics is the patient/
62
family (or community, for those practicing in because of its importance in preventing medi-
community health) in the context of a trusting cation errors. Much effort has been devoted
relationship. over the years to improving structures and
processes related to medication reconcilia-
For most patients/families, gone are the days tion at Lourdes through an interdisciplinary
of paternalistic medical care. Although patients committee, the ADE Team. The vision then
may not want to make all health care decisions and now was that every person presenting for
by themselves, or even participate in decision service at any site would have an accurate,
making, the trend toward shared decision up-to-date electronic or paper medication list.
making is taking hold. The Lourdes ADE Team developed a strate-
gic plan with short- and long-term goals and
objectives to support accurate and efficient
admission, transfer, and discharge medication
reconciliation. That plan involved both internal
Although patients may
and external (that is, community) opportuni-
not want to make all
ties to get the message out. The ADE Team
health care decisions
has developed and submitted proposals to
by themselves, or even
the organization’s executive team over the
participate in decision
years, requesting fiscal resources identified
making, the trend
as needed for ongoing activities to support
toward shared decision
the ADE Team’s vision. With interdisciplinary
making is taking hold.
teamwork and collaboration, the ADE Team
has developed, implemented, evaluated, and
further refined its processes.
For decision making regarding medication Nurses can be transformational leaders.

use to be truly informed, it is essential that Nurses often are the first health care provid-
the relationship be genuine and that patients ers patients see when they present for ser-
be honest in reporting all medication use, vice. As developers and implementers of new
including prescription, over-the-counter, and processes, nurses can be the leaders in the
even illicit drugs. This is a critical component, transformation of existing processes. Specifi-
and the rationale must be communicated to cally, nurses can be transformational leaders
the patient. Only by honest, thorough report- by ensuring that there are structures and pro-
ing can health care be safe and effective and cesses in place to support patients/families
avoid unnecessary risks. and health care providers in medication recon-
ciliation throughout the continuum of care. The
At Lourdes Hospital, passion for our work, nurses at Lourdes, with support of organiza-
along with lessons learned along the way, have tion leaders, have continued the work begun in
contributed to the continued sustainability of 2004 with projects that focus on getting nurses
medication reconciliation at our institution. involved as leaders through their roles in the
creation of processes in which they engage
The ADE Team Strategic Plan patients, families, the community, and other
Lourdes Hospital’s focus on medication rec- health care organizations as partners.
onciliation started in 2004–2005 with develop-
ment of the Adverse Drug Event (ADE) project,
conducted in collaboration with the IHI. Medi-
cation reconciliation was a part of that project
63
FIGURE 3-1. Professional Practice Model
Source: Our Lady of Lourdes Memorial Hospital, Inc., Binghamton, NY. Reprinted with permission.
FIGURE 3-2. Care Delivery System
64
Medication Lists card holders in waiting rooms, exam rooms,

and at checkout desks.
As has already been noted, medication recon-
ciliation begins and ends with an established TIP #2: Keep your design simple.
format, such as a medication list. During the
process of compiling and updating the medi- Having one standardized design for medica-
cation lists used at Lourdes Hospital, nurses tion cards ensures that patients/families see
and other caregivers remind patients/families the same message throughout the organi-
that they have responsibilities related to their zation, which reinforces the importance of
health care, including keeping accurate, up- this process to the patient and the organiza-
to-date medication information and bringing it tion. The medication card currently in use at
with them to every health care visit. This helps Lourdes has evolved over the years. It is avail-
to reinforce the concept that patients/families able on card stock as well as regular-weight
(or authorized representatives) are essen- paper. Both versions fold up to easily fit in a
tial members of the team that work together wallet. The font is at least 12 point for ease
to reduce the risk of medication errors. This of readability. The column headers on the
partnership is so vital that The Joint Com- medication card reflect the data collected and
mission, in NPSG.03.06.01, has included the documented in the EHR. (See Figure 3-3 on
patient and family in the responsibility of com- page 66.) The column headers on the paper
municating updated medications to the next form at sites of service still using a paper pro-
provider of care (see “The Joint Commission’s cess (and during downtime) mirror those on
NPSG.03.06.01” on page 60). the medication card. Because EHR entries in
the medication list are at the “person level,”
Medication Lists: Making It Easy To Do the information is retained from one encounter
the Right Thing . . . And Do It Well to the next. Not only does this help ensure a
more complete and accurate list, it also makes
TIP #1: Have blank medication updating a home medication list more efficient
cards accessible to patients/ on subsequent health care visits.
families—and within easy reach
of staff. Medication Lists: Serving as Interpreters
One of the ways to engage the patients/fami- TIP #3: Involve patients/families
lies in the updating of medication information when creating and updating
is through the use of medication cards, which medication lists: You will find
can be offered to patients who present for ser- “teachable moments” at every
vice without accurate information about the encounter—take advantage of
medications they are taking. At Lourdes, there them.
are wall-mounted and desktop acrylic card
holders for every practice site, and all sites For sites using EHRs, Lourdes nurses show
stock the same card. That makes it easy for patients/families the computer screen dis-
service sites to reorder cards in bulk quantity. playing data previously or currently being
The ED nurses keep a supply of medication entered. This facilitates accurate communica-
cards “at their fingertips” at the Triage Desk. tion between patients/families and members
The inpatient nursing units mounted holders of the health care team because names and
on or near the nurses’ stations to be visible and doses can be misunderstood when verbally
accessible to patients/families, visitors, and repeated. Many medications are dispensed
staff. The primary care sites have medication as generic products or substitutions based
65
FIGURE 3-3. Medication Cards
These cards are used at Our Lady of Lourdes Memorial Hospital to facilitate patient partici-
pation in medication reconciliation.
SIDE 1
SIDE 2
66
on pharmacies’ formularies. Patients/fami- Medication Lists: Making It Fun!

lies can become easily confused, particularly
when third-party payers shift from one phar- TIP #5: Create a program slogan and
macy/drug supplier to another. Clarifying with visual message that people will
patients/families the purposes for which medi- remember.
cations are being taken is essential for provid-
ers who may be prescribing new medications Medication reconciliation is hard work. Laugh-
or writing admission orders. EHRs that display ter truly lightens one’s burdens. Every orga-
both trade and generic names of medica- nization has talent—oftentimes unknown and
tions during data entry are a tool to educate untapped. Allowing a team to be creative and
patients/families. letting a project take on a life of its own creates
camaraderie and makes work fun. Organiza-
TIP #4: Have drug references at hand. tions can look outside the team, if necessary,
for design or artwork (word of mouth will often
Easy access to Web-based drug references lead to good resources). For maximum effect,
from within EHRs facilitates accurate data it’s a good idea to integrate evidence-based
entry and is another resource tool for edu- practices (strategies) of the marketing indus-
cating patients/families about their medica- try: for example, bright colors attract attention.
tions. Capability to print reference materials Another good guideline is to keep the text sim-
from the “bedside,” while documenting in the ple to highlight the importance of the message
EHR, enables nurses to tailor their teach- the team wants to convey. An important check-
ing to patients’/families’ identified needs and point is the question, “Does the reader ‘get’
styles of learning. Hospital pharmacists are the message by looking at the sign?” Finally,
a continual resource and are expanding their many organizations have corporate identity
responsibilities to be more involved on the programs and public relations departments
clinical units. They are available to discuss that will often insist on input into the design
medication management with providers and of materials the public will see. Therefore, be
nurses and to provide information about spe- sure to check that your signage is not only
cific medications. consistent with the organization’s efforts but
also presents a consistent and legible mes-
sage to both public and staff.
An illustrative example. One of the Lourdes

Capability to print team’s projects was to create a slogan for a
reference materials community education program. The team
from the “bedside,” developed several potential slogans, revising
while documenting over and over until they were satisfied. As the
in the EHR, enables slogan evolved, team members began creat-
nurses to tailor ing ideas for cartoon characters that coordi-
their teaching to nated with the slogan (see Figure 3-4 on page
patients’/families’ 68). One of the team members knew of an
identified needs and associate with artistic talent—and so simple
styles of learning. characters came to life.
67
FIGURE 3-4. Community Medication Education Program Slogans
Medication Lists: Establishing Your education should be. The public relations or
Presence in Your Community marketing departments of health care organi-
zations will recognize the opportunity to pub-
TIP #6: Tap into every resource you can licize medication safety efforts, and so they
find. are valuable resources not to be overlooked.
A team can identify who manages the organi-
Consider how important medication safety is zation’s Web site and get him or her involved
to a community and consequently how impor- in helping educate internal and external part-
tant the nurses’ role in patient/community ners in medication reconciliation and the use
68
of medication lists and cards. It may be useful example, that hospitals and EDs have pro-
also to consider making reasonable requests cesses in place (electronic or paper) to high-
for assistance from an organization’s founda- light missing or incomplete medication data.
tion or from volunteer groups associated with It is also important that the processes put in
the organization. Lourdes is blessed with an place are user-friendly for the prescribers.
active, well-supported Auxiliary. Volunteers Organizations should consider how prescrib-
from the Auxiliary stock the medication card ers will know that information is missing and
holders located in common (public) areas that they will need to provide those data when
such as waiting rooms. completing admission medication reconcili-
ation information. For example, at Lourdes,
Medication Lists: Communicating the information technology analyst was able
Throughout the Continuum to code the electronically generated paper
form initially used for admission medication
TIP #7: Ask questions: It can save lives! reconciliation so that missing data elements DEFINED: RHIO and HIE
of the medication order were highlighted (see An RHIO is “an organization
In any health care environment experiencing Figure 3-5 on page 70). After Lourdes imple- that oversees and governs the
high volumes and constant interruptions, an mented this change, the number of orders exchange of health-related
information among organizations
ADE can occur easily unless there is constant sent to the pharmacy with missing data was
according to nationally recog-
attention to detail. Everyone has a responsi- reduced significantly. This reduced the num-
nized standards.”14 RHIOs enable
bility to question patient-specific information: ber of telephone calls to prescribers for order health information exchange
Ask questions to verify that all documentation clarification and shortened time to administer (HIE), the electronic communica-
is accurate. of medications. tion of health care information
among organizations.14
Understanding the transfer of information. Sharing complete information via RHIOs.
Remember, a patient travels through a mul- A community may serve patients who spend
titude of settings during the course of treat- time throughout the year in both the northern
ment, and effective communication includes and southern regions of a country. Or a com-
an understanding of how each person, repre- munity may be on a well-traveled roadway with
senting the patient from each setting, provides travelers who might need health care. Nurses
the most up-to-date and accurate information. should ask those transient patients if their
The reality is that not every patient will pres- organization is providing all the medication
ent for service with an up-to-date medication information the patients and their other primary
list. Those assigned to creating and updat- care providers need. In the United States,
ing medication lists are expected to make a many communities are establishing regional
“good-faith” effort, doing the best possible health information organizations (RHIOs) to
given the resources available. Communicating enable health information exchange (HIE).
clearly can avoid unnecessary questions and The goal of HIE is “to facilitate access to and
the potential for error. retrieval of clinical data to provide safer, more
timely, efficient, effective, equitable, patient-
Designing flexible processes. Being flexible centered care.”14 RHIOs bring together health
and open to change can also avoid unnec- care stakeholders within a defined geographic
essary questions and the potential for error. area and govern HIE among them for the
Processes that worked one or two years ago purpose of improving health and care in that
may no longer work today. It is essential, for community.
69
FIGURE 3-5. Medication Reconciliation on Admission Form
Source: Cerner Corporation. Reprinted with permission.
70
An organization’s clinical nurse informaticists to an EHR. Lourdes, for example, continues to

should be engaged as ad hoc members of a give primary care providers paper summaries
medication reconciliation team to understand of visits, including dictated and transcribed
the organization’s planned or current participa- discharge summaries, as well as clinical sum-
tion in an RHIO and how the security of data maries from nursing that are faxed or sent via
is guaranteed. The team can advocate for interoffice mail.
electronic medication lists to be included in
the information being shared with the RHIO. As the database becomes populated, main-
And then that team can educate the commu- taining medication lists becomes less time-
nity about the value of the RHIO, including consuming. However, populating the database
the requirement that patients must consent to requires time. At Lourdes it has taken about
allow health care organizations and providers two years for the database to be complete
to access their data. enough for direct care nurses to recognize
time savings.
Medication Lists: Using Technology
TIP #9: Ask the consumers of your
TIP #8: Make the initial investment of discharge information what
time and effort to create elec- they need.
tronic medication lists.
The consumers of an institution’s discharge
The result is that medication information is information often include health care providers
easily accessible—and will pay for itself in the located outside the local region, and some-
future. times even across the country or around the
world. Your organization should ask these
The advantage of EHRs is the ability to mean- providers if the information that you supply
ingfully use the massive amount of data now after completing discharge medication rec-
being stored. At Lourdes, all primary care, onciliation is meeting their needs. Lourdes
ambulatory services, and home care providers found opportunities for improvement in this
have access to the EHR used in the hospital area after transitioning to an EHR. Home care
and ED. Many independent providers have agencies and extended care facilities needed
remote access into the EHR. At other organi- fewer documents provided to them—and they
zations, medical staff may have just managed didn’t want duplicate information on paper: Too
to get their work flow related to medication rec- many documents with the same information
onciliation into a rhythm in a paper world—and presented in a different format can be confus-
now they are faced with the challenges of cre- ing and cause errors as well.
ating and updating medication lists and com-
pleting medication reconciliation electronically.
Simplicity in the functionality of the EHR will
help promote buy-in of all stakeholders as they Too many documents
transition from a paper record. Transformation with the same
occurs when the stakeholders recognize the information presented
efficiency in their work flow and effectiveness in a different format
in communication. can be confusing and
cause errors as well.
During the interim period, it’s best to main-
tain paper medication lists until stakeholders
demonstrate that they are ready to transition
71
To facilitate working with outside providers, a institute a change that has been suggested
medication reconciliation team should sched- and to overcome barriers that arise are
ule meetings and review the options the vital to the team’s success. The system
organization’s EHR format has for providing leaders understand both the implications
discharge information and summaries of care. of the proposed change for various parts
During this process, the team should consider of the system and the more remote conse-
options for reducing paperwork transmitted quences such a change might trigger.
out of the organization. The team might also These members must have the authority to
consider including laypersons in designing allocate the time and resources the team
the home medication list through such struc- needs to achieve its aim. Included in this
tures as patient advisory committees. A patient level of membership is the team’s “execu-
advisory committee can offer insight regarding tive sponsor.”
medications that other health care providers • Clinical Technical Expertise: Technical
(whether local, regional, national, or interna- experts are those who know the subject inti-
tional) need in order to ensure that the organi- mately and who understand the processes
zation’s medication information is clearly and of care. Experts on improvement methods
accurately communicated. can provide additional technical support
by helping the team determine what to
measure; assisting in design of simple,
Medication Reconciliation:
effective measurement tools; and providing
Accountability of All Team guidance on collection, interpretation, and
Members display of data. Some organizations may
refer to them as “subject matter experts”
TIP #10: Identify “WWWH”—Who will do (SMEs). Included in this level of member-
What When . . . and How? ship are nurses, physicians (particularly
the physician who will serve as the team’s
Regardless of the practice setting, all health physician champion for the project), phar-
care professionals are accountable to those macists, quality specialists, educators, and
they serve. Responsibility for implementa- information technology analysts.
tion of successful medication reconciliation • Day-to-Day Leadership: Day-to-day lead-
processes should lie with a committee whose ers drive the project. They ensure that tests
members determine who will do what, when of change are implemented and oversee
Formula for Accountability it will be done, and how it will be done. Team data collection. It is important that day-to-
R + A + A: Responsibility, members should include representatives day leaders understand not only the details
Authority, Accountability15
from all service sites and levels involved in of the system but also the various effects of
the process (for example, direct care nurses, making a change(s) in the system. These
pharmacists, providers). The organization members also need to be able to work
should clearly define the core members who effectively with the physician champion(s).
will establish goals, test changes, and evalu-
ate the effectiveness of the changes. It should The team can develop a checklist to ensure
also define how often the team will meet and that all facets of the organization’s medication
maintain a meeting schedule. The IHI sug- reconciliation processes have been consid-
gests that for the team to be effective, it should ered and responsibilities assigned. The Ameri-
also include members with the following types can Nurses Association Standards of Practice
of skills16: (assess, diagnose, identify outcomes, plan,
• System Leadership: Individuals with implement, and evaluate)17 and the IHI’s use of
enough authority in the organization to the Plan-Do-Study-Act methodology for testing
72
SIDEBAR 3-1. Design and Implementation Checklist
Clinical Documentation and Medication Ordering • Who will support nursing and medical staff during
(Paper; Electronic) scheduled, prolonged downtimes, such as during
• How will medication lists (home and current) be system upgrades?
documented? • Does your organization employ “super-users”?
• Who is responsible for developing paper forms?
• What committee(s) approves forms? Monitoring Empiric Outcomes (Accountability at
• Through what medical staff committees does your Every Level)
process need to be vetted? • Who reports adverse drug events?
• Do those at the point of care have a process to
Policy and Procedure Development and Regularly report errors or near misses?
Scheduled Review/Revisions • Have you partnered with patients to “Speak Up”?18
• Are policies and procedures approved through The Joint Commission’s Speak Up™ program
a shared governance/shared decision-making provides excellent resources for patients concern-
model? ing the safe use of medications and medication
• What is the standard for policy review at your reconciliation. Encouraging patients to speak up
organization? can also help to identify errors and near misses.
• How is the “policy owner” notified that the policy is Speak Up brochures can be downloaded as PDF
due for regular review? files, and are available at the Joint Commis-
• If your organization’s standards of care or regula- sion’s Web site: http://www.jointcommission.org/
tory requirements change, what is the process for speakup.aspx.
policy review and revisions? • Is your organization transparent?
• Who monitors process and outcome metrics? Is
Nursing and Medical Staff Education there peer review?
• Is your process paper based or electronic? • How are data shared at the unit/department and
• How will you transition from paper to electronic? organization levels? How often? Who is assigned
• Who educates nursing and medical staff about to develop the reports? What format is used?
your processes for medication reconciliation? What aggregated reports are of value to direct
• Is training needed only at orientation? Do nursing, care providers, department managers, execu-
medical, and other disciplines need “refresher tives, and the Board of Directors?
training” at regular intervals? • How quickly can nursing and associated staff
• Should you employ classroom training, computer- respond and recover when system issues create
based training, or a combination of the two? risk for even one patient? How are structures (for
• What tools can your educators develop to clearly example, electronic and paper forms) modified?
articulate each professional’s role in medication Who is responsible for owning system (structure)
reconciliation? Does your organization utilize work changes?
flows? PowerPoint presentations?
• Can references be posted on your intranet? Who
monitors those references to ensure that they are Source: Our Lady of Lourdes Memorial Hospital, Inc.,
Binghamton, NY. Reprinted with permission.
always up-to-date?
change16 provide frameworks, ensuring that the A Special Case: Medication

evaluation phase (“How do you know you have Reconciliation in the ED
been successful?”) is not neglected. Lourdes
Hospital’s Design and Implementation Checklist As has been stressed in this chapter, medi-
shown in Sidebar 3-1 above provides a template cation reconciliation starts with the patient
for a medication reconciliation team’s work. presenting at the site of service and the
73
consequent creation or updating of the medi- community pharmacies, other health care pro-
cation reconciliation list. The responsibility viders, and family members at home who can
for updating the medication list belongs to a read the prescription labels.
designated health care provider—whether it
be a triage nurse in the ED, a medical office Conclusion
assistant or nurse in the physician’s office, or
a respiratory therapist in an outpatient testing The challenge for all health care providers is
area. to continuously pay close attention to detail.
This includes carefully double-checking any
At Lourdes, medication reconciliation was a medication information with which the patient
special challenge in the ED due to the follow- presents, as well as eliciting from the patient/
ing barriers: family all over-the-counter medications, herbal
• It is time-consuming for nurses. or dietary supplements, investigational drugs,
• Patients and families have difficulty accu- and illicit drugs that he or she is taking. This
rately reporting information. They often are also presents an opportunity for educating
stressed by the situation precipitating their patients/families regarding their medications.
ED visit and are not able to focus enough to Nurses—and other health care workers—
provide the details being requested regard- should never assume that medications in pre-
ing medications, or the person who has the scription bottles or those listed on medication
accurate information may not be present at cards are correct, current, or prescribed.
the time of initial presentation.
• Visits to the ED are often unplanned, and Medication errors may take many forms—and
patients/families do not have the time to come from various sources: Patients make
collect medication bottles and information. errors, providers make errors, pharmacists
make errors, nurses make errors. As new med-
Incorporating an MRPT ications and treatments develop, health care
The Lourdes team researched other mod- workers are challenged to assist patients in
els for collecting information related to home understanding their medication management
medications and decided to implement a care and ensuring adherence to their treatments.
delivery model that includes a Medication Each day—multiple times a day—health care
Reconciliation Pharmacy Technician (MRPT) providers must ask, “Does the medication
position. The role of the MRPT is to create and make sense? Does it fit the patient’s history
update medication lists for ED patients, with or present illness?” At each point of service,
his or her priority being patients admitted to medication reconciliation ensures that what
an inpatient unit. The MRPT’s second priority the provider orders is what the patient under-
is patients with extensive medication lists who stands and takes as part of a program of care.
are being discharged from the ED, but have
the potential to visit the ED in the future. On References
days when ED volume is lower than normal, 1. Institute for Safe Medication Practices (ISMP):
the MRPT assists on the inpatient nursing A Call to Action: Protecting United States Citizens
units with direct admissions (that is, patients from Inappropriate Medication Use: A White
arriving from provider offices). By allocat- Paper on Medication Safety in the United States
ing resources for this position, Lourdes has and the Role of Community Pharmacists. Hunt-
been able to ensure a more accurate medica- ingdon Valley, PA: ISMP, 2007.
tion list because the MRPT dedicates time to 2. WHO Collaborating Centre for Patient Safety
using all resources available, including calling Solutions: Assuring medication accuracy at
74
transitions in care. Patient Safety 10. Cornish P.L., et al.: Unintended medication
Solutions 1(solution 6), May 2007. discrepancies at the time of hospital admission.
http://www.ccforpatientsafety.org/common/ Arch Intern Med 165:424–429, Feb. 28, 2005.
pdfs/fpdf/presskit/PS-Solution6.pdf (accessed 11. Sullivan C., et al.: Medication reconciliation
Apr. 22, 2011). in the acute care setting: opportunity and chal-
3. Kohn L.T., Corrigan J.M., Donaldson M.S. lenge for nursing. J Nurs Care Qual 20:95–98,
(eds); Committee on Quality of Health Care Apr.–Jun. 2005.
in America, Institute of Medicine: To Err Is 12. Institute for Healthcare Improvement:
Human: Building a Safer Health System. Wash- Percent of Unreconciled Medications.
ington, DC: National Academy Press, 2000. http://www.ihi.org/knowledge/Pages/Measures/
4. Kaiser Family Foundation: Health Care Costs: A PercentofUnreconciledMedications.aspx
Primer—Key Information on Health Care Costs (accessed Apr. 22, 2011).
and Their Impact. Mar. 2009. 13. Pronovost P., et al.: Medication reconciliation:
http://www.kff.org/insurance/7670.cfm A practical tool to reduce the risk of medication
(accessed Apr. 9, 2011). errors. J Crit Care 18:201–205, Dec. 2003.
5. Massachusetts Coalition for the Prevention of 14. Healthcare Information and Management
Medical Errors: [Homepage]. Systems Society: Definitions & Acronyms. http://
www.macoalition.org (accessed Apr. 22, 2011). www.himss.org/content/files/
6. The Joint Commission: Using medication RHIO_Definitions_Acronyms.pdf (accessed
reconciliation to prevent errors. Sentinel Aug. 3, 2011).
Event Alert 35, Jan. 25, 2006. 15. Koloroutis M. (ed.): Relationship-Based Care: A
http://www.jointcommission.org/assets/ Model for Transforming Practice. Minneapolis:
1/18/SEA-35.pdf/ (accessed Apr. 22, 2011). Creative Health Care Management, 2004.
7. Kizer K.W., Blum L.N.: Safe practices for 16. Institute for Healthcare Improvement: Science of
better health care. In Henriksen K., et al. (eds.): Improvement: Forming the Team.
Advances in Patient Safety: From Research to http://www.ihi.org/knowledge/Pages/
Implementation, vol. 4: Programs, Tools, and HowtoImprove/ScienceofImprovement
Products. Rockville, MD: Agency for Healthcare FormingtheTeam.aspx (accessed Apr. 9, 2011).
Research and Quality, 2005, pp. 23–32. 17. American Nurses Association (ANA): Nursing:
8. National Quality Forum (NQF): Safe Practices Scope and Standards of Practice, 2nd ed. Silver
for Better Healthcare—2009 Update: A Consensus Spring, MD: ANA, 2010.
Report. Washington, DC: NQF, 2009. 18. The Joint Commission: Speak Up
9. WHO Collaborating Centre for Patient Initiatives: The Joint Commission’s
Safety Solutions: Patient Safety Solutions Award-Winning Patient Safety Program.
Preamble—May 2007. May 2007. http://www.jointcommission.org/
http://www.ccforpatientsafety.org/common/ speakup.aspx (accessed Apr. 9, 2011).
pdfs/fpdf/presskit/Preamble.pdf (accessed Apr.
22, 2011).
75
FOCUS
Transitions in Care:
Communication of Medication Information Between Health Care Settings
One of the most critical issues in health care is effective communication among caregivers—
particularly at transitions in care. Ineffective communication results in more than two-thirds
of treatment errors in health care.1 And when patients are transferred between health care set-
tings, the potential for medication errors increases due to ineffective documentation, transcrip-
tion, and provider–provider or patient–provider communication.2
Transitions Between Acute Care and Other Settings

Many studies have shown that medication discrepancies3 occur upon transfer between acute
care and long term care, transfer to home care organizations, and upon discharge home from
the hospital. Medication discrepancies can be defined as “unexplained differences among docu-
mented regimens across different sites of care.”4
Long term care transitions. Tjia et al. found that three out of every four patients who
transferred from the hospital to a skilled nursing facility in Massachusetts had a medication
discrepancy, representing one-fifth of all medication prescribed on admission to the nursing
home.4 Thereafter, when patients are admitted to the hospital from a nursing home, a study
found that 24% of transfer documents lacked medication information.5 Furthermore, among
residents whose medications were changed while they transferred between nursing homes and
hospitals, 20% experienced an adverse drug event (ADE). Most of the changes to the medica-
tions occurred in the hospital, but the ADE occurred after the patient returned to the nursing
home.6
Hospice care transitions. Another study that examined transitions into hospice care found at
least one medication discrepancy per patient, with an average of 8.7 discrepancies per patient.7
Behavioral health care transitions. In behavioral health care, primary care providers and
psychiatrists have not determined who is responsible for monitoring and maintaining a patient’s
medication list. One study found that the primary care provider was likely to omit psycho-
tropic medications on his or her medication list for the individual, whareas the psychiatrist
was likely to maintain a list of only psychotropic medications.8 Furthermore, a study in the
United Kingdom found many medication discrepancies for individuals with mental illnesses as
they transferred between primary and secondary care settings. For example, researchers found
a 69% discrepancy rate at the time of admission (medications listed on hospital admission
forms were different from those on the physician’s list of medications for the patient prior to
admission).8 Then, at discharge, there was a 43% discrepancy rate between the medication list
according to the discharge summary and the physician’s list of medications for the patient after
discharge.8
76
FOCUS: Transitions in Care
FOCUS
(continued)
Strategies for Reducing Medication Errors That Occur at Transitions in Care
In addition to performing thorough and consistent medication reconciliation, nurses can help
to reduce medication discrepancies at transfer by using the following strategies:
• Target High-Alert Medications: Include high-alert medication discrepancies (such as opioid
and nonopioid analgesics, warfarin, benzodiazepines, insulin, and antipsychotic agents) in
clinical decision support systems (CDSSs) for nursing homes and hospitals. The CDSS
should alert care providers to the potential for a medication discrepancy based on the
patient’s medications.2 (See Chapter 2 for more on the use of a CDSS.)
• Create Transition Protocols for Managing Information Communication: If a patient popula-
tion typically transfers from one care setting to another (such as nursing home patients
who transfer from the hospital and then back), create a protocol for managing the com-
munication of information during these transfers.5 Some organizations have improved
communication when transferring patients between emergency department (ED) staff and
nursing home staff by using fax machines, audio recordings, and standardized communica-
tion forms.9 If the patient is transferring from the nursing home to the ED, the information
communicated should include the resident’s medical history, advance directives, medica-
tions, baseline condition, and nursing home contact information.9 If the patient is trans-
ferring from the ED to the nursing home, the information communicated should include
the ED diagnosis, treatment received, results of diagnostic tests, and recommendations for
treatment and follow-up.9
• Prevent Transitions in Care: As many as one-third of nursing home transfers to the hospital
are avoidable.10 Long term care organizations can reduce the number of residents transferred
to the hospital by expanding services within their organization, such as adding advance
practice nurses or physician assistants, providing intravenous therapy, or improving access
to preventive or outpatient care to better manage chronic conditions without exacerba-
tions that may require hospitalization.9,10 Studies have also shown that when there are more
nurses on staff at a long term care organization, the rate of hospitalization among residents
is decreased.9
References
1. Maidment I.D., Lelliott P., Paton C.: Medication errors in mental healthcare: A systematic review. Qual
Saf Health Care 15:409–413, Dec. 2006.
2. Boockvar K.S., et al.: Prescribing discrepancies likely to cause adverse drug events after patient transfer.
Qual Saf Health Care 18:32–36, Feb. 2009.
3. Stock R., Scott J., Gurtel S.: Using an electronic prescribing system to ensure accurate medication lists in
a large multidisciplinary medical group. Jt Comm J Qual Patient Saf 35:271–277, May 2009.
4. Tjia J., et al.: Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern
Med 24:630–635, May 2009.
77
FOCUS
(continued)
5. Boockvar K.S., et al.: Medication reconciliation for reducing drug-discrepancy adverse events. Am J
Geriatr Pharmacother 4:236–243, Sep. 2006.
6. Boockvar K., et al.: Adverse events due to discontinuations in drug use and dose changes in patients
transferred between acute and long-term care facilities. Arch Intern Med 164:545–550, Mar. 8, 2004.
7. Kemp L.O., et al.: Medication reconciliation in hospice: A pilot study. Am J Hosp Palliat Care 26:
193–199, Jun.–Jul. 2009.
8. Procyshyn R.M., et al.: Medication errors in psychiatry: A comprehensive review. CNS Drugs 24:595–
609, Jul.1, 2010.
9. Murray L.M., Laditka S.B.: Care transitions by older adults from nursing homes to hospitals: Implica-
tions for long-term care practice, geriatrics education, and research. J Am Med Dir Assoc 11:231–238,
May 2010.
10. LaMantia M.A., et al.: Interventions to improve transitional care between nursing homes and hospitals: A
systematic review. J Am Geriatr Soc 58:777–782, Apr. 2010.
78
FOCUS: Patient Education
FOCUS
Patient Education:
Addressing Low Health Literacy Among Home Care Aides
Low health literacy skills are associated with misunderstanding of and lack of adherence to
medication regimens, increased hospitalizations, and poor health outcomes.1 It is particularly
important to address health literacy issues with patients receiving care outside of the hospi-
tal because they must manage their care independently with information and guidance from
health care providers and without continuous oversight.2 A recent study revealed that, in home
care, caregivers with low health literacy may be part of the problem. The researchers found that
35.7% of paid home health aides for seniors had low health literacy; however, 85% of all these
caregivers were required to perform health care–related tasks (such as medication sorting and
following physician instructions) regardless of their health literacy level.3
Strategies to Address Health Literacy Issues Among Patients and Aides in
Home Care
To ensure that patients and their home health aides understand the health care information
presented to them, nurses should consider the following strategies:
• Improve Oral Communication: Speak slowly and clearly, use short sentences, avoid medical
jargon, and limit the information to three to five key points and repeat those points, draw-
ing or referring to pictures whenever possible.
• Improve Written Communication: Make sure written information provided to patients and
home health aides is clear and concise, is written at a sixth-grade or lower reading level,
includes pictures or illustrations, and is available in the languages commonly used by the
patient and home health aide.4 Written communication should, like oral communication,
avoid using medical jargon.1
• Use Standardized Methods: Make use of effective standardized methods, such as the teach-
back method to assess understanding (see Chapter 1), brown-bag meetings (see Chapter 6) to
review and reinforce medication regimens, and the “Ask Me 3” education program, in which
patients and their home health aides are asked to make sure they know the answer to these
three questions after interacting with health care providers1: (1) What is my/my patient’s
main problem? (2) What do I need to do? (3) Why is it important for me to do this?
References
1. DeWalt D.A., et al.: North Carolina Network Consortium, Cecil G. Sheps Center for Health Services
Research, University of North Carolina: Health Literacy Universal Precautions Toolkit. Agency
for Healthcare Research and Quality, Apr. 2010. http://www.ahrq.gov/qual/literacy/
healthliteracytoolkit.pdf (accessed Apr. 3, 2011).
2. The Joint Commission: Addressing Patients’ Health Literacy Needs. Oak Brook, IL: Joint Commission
Resources, 2008.
3. Lindquist L.A., et al.: Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med
26:474–479, May 2011.
4. Safeer R.S., Keenan J.: Health literacy: The gap between physicians and patients. Am Fam Physician
72:463–468, Aug. 1, 2005.
79
CHAPTER FOUR Medication ErrORS:
Risk Management
AUTHOR: Grena Porto, R.N., M.S., A.R.M., C.P.H.R.M., Principal, QRS Healthcare Consulting, LLC,
Hockessin, Delaware, and member of The Joint Commission Patient Safety Advisory Group
A nurse is preparing to distribute medications • Why don’t extensive and expensive invest-
to her patients. To her dismay, she finds that a ments in medication safety technology
medication for one of her patients is missing, and consistently prevent even simple medica-
this will not only cause her to be late in adminis- tion errors?
tering the drug to her patient, it will also make
more work for her as she calls the pharmacy for Many nurse leaders would be tempted to
the missing medication and completes the required address this infraction by disciplining the
incident report. The nurse decides to “borrow” the nurse because the event involved clear vio-
medication from the cassette of another patient lation of policy. Others, in an attempt to be
who is in the operating room, intending to replace less punitive, would resort to re-educating the
it later. That afternoon when replacing the bor- nurse about appropriate medication adminis-
rowed medication, the nurse notices that the dosage tration procedures—the “3 strikes and you’re
she borrowed was higher than that prescribed for educated” approach.1 Both approaches, how-
her patient. Her patient received an overdose, and ever, violate one of the most fundamental
ө
the nurse must now complete an incident report, tenets of effective risk management and per-
but instead of reporting the pharmacy’s error, she formance improvement: identifying and cor-
must report her own. recting underlying system causes of unwanted
variation, rather than focusing on “fixing” indi-
When the nurse manager reviews the incident viduals who make errors. These approaches
report the following morning, she is disturbed to reach for easy solutions to complex problems,
learn that medications are still not arriving on the relying on the following fundamentally flawed
unit on time. Even more disturbing, it appears assumptions:
that nurses continue to employ workarounds to • Patient safety is best maintained by follow-
cope with the problem, and patients are getting ing every policy every time.
hurt in the process. The nurse manager is frustrated • Policy violations are motivated by laziness
because she has dealt with this problem repeatedly and disregard for safety.
over the years without any success. With mounting • Mistakes are caused by lack of knowledge,
anger and dread, the nurse manager contemplates and staff members can be “inoculated”
the next steps that must be taken. against making mistakes through training
and retraining.
This scenario highlights common and frustrat- • Mistakes happen when people are careless
ing challenges for nurse leaders: and can be avoided by simply being more
• Why do the same errors keep happening careful.
over and over again?
• Why don’t nurses follow well-established In fact, as we know now, errors are complex
protocols, even after they have been and evolve through the interplay of a variety of
repeatedly educated about them? equally complex factors. Most errors are rooted
81
in systemic flaws, and some of those flaws are A Risk Management Approach to
themselves part of systems designed to pre- Medication Safety
vent errors in the first place. For example, in
the scenario described above, a system put in The discipline of risk management offers nurse
place to prevent medication dispensing errors leaders a comprehensive framework within
by nurses—automated dispensing machines which to identify, evaluate, and take actions
(ADMs)—led to the lack of availability of a to prevent or mitigate medication errors. This
needed medication, which then led to the medi- chapter will illustrate how risk management
cation error. Also, this incident demonstrates that principles can be applied to the problem of
technology solutions designed to prevent errors medication errors, and how this approach
sometimes lead nurses to assume that simple offers nurse leaders the greatest chance for
manual checks, like verifying dose through success.
visual inspection or checking the “five rights,” are
no longer required. Effective risk management involves a five-step
process4:
Other factors, including features of the work Step 1: Identification of the risk
environment and innate human vulnerabilities, Step 2: Risk analysis and investigation
also play a role in the genesis of error. Leape Step 3: Selection of the best risk
describes a variety of “slips, trips, and lapses” management strategy
that human beings are particularly vulnerable to Step 4: Implementation of the chosen
and emphasizes that training and vigilance are strategy
not sufficient to guard against such mistakes.2 Step 5: Monitoring the results and making
A common misconception among health care needed modifications
workers and managers alike is that sufficient
training, experience, and carefulness can pre- Thus, employing a risk management approach
vent human beings from making errors. In fact, to medication safety and error prevention
DEFINED: Risk Management all human beings, regardless of training, exper- means that nurse leaders must go well beyond
Risk management is defined as
tise, and good intentions, err frequently and in reviewing incident reports and revising poli-
“the process of making and car-
predictable ways. All human beings have poor cies and training.
rying out decisions that will help
prevent adverse consequences short-term memory, for example, and are vulner-
and minimize the negative able to vigilance fatigue. Thus, work processes Risk Identification
effects of accidental losses on that require or allow the user to rely on memory
an organization.”3(p 625) to retrieve critical pieces of information or that To address medication error risk, it must first
require vigilance and concentration on the part be identified. Review of incident reports is
of the user to avoid error are doomed to fail. (For probably the most common method of identify-
more information about the role of human error ing medication errors used by nurse leaders,
and human factors in medication safety, see but this approach may be too limited and can
Chapter 1.) be supplemented by use of other strategies.
In addition, no matter how well designed the Revisiting Incident Reporting

system, errors will always occur. It is simply not Still a cornerstone of organizational medica-
possible to design a process that is completely tion safety programs, incident reporting serves
error proof, particularly if human beings are part several important functions. First, it provides an
of the process. Understanding these principles “early warning system” that identifies circum-
is essential to designing appropriate responses stances or factors that can give rise to patient
and interventions in response to errors. injury. When staff use the incident reporting
system to report “close calls,” organizational
82
CHAPTER FOUR: Medication Errors: Risk Management
leaders have the opportunity to intervene and sources of error. By examining trends in
prevent an error before patient harm occurs. reported incidents and identifying patterns
Unfortunately, reporting close calls is not as in reporting, such as location, time of day, or
common as reporting events that result in even medication involved, system flaws and
injury, due in part to a lack of understanding by possible solutions can be identified.
staff of the importance of doing so. Also, staff
perception that reporting an incident can have Evaluating Work Environment and
disciplinary consequences hinders willingness Work Processes
to report incidents other than those that cannot There are other equally important and effec-
be hidden. tive mechanisms available to nurse leaders
for identifying medication error risks. Regular
It is therefore critical that nurse leaders, risk patient safety rounding is one example. As
managers, and all health care administrators noted above, errors are the result of the inter-
clearly establish the primary purpose of inci- play of a variety of factors. Understanding how Defined: Root Cause Analysis
dent reporting as a patient safety tool rather medication errors occur requires that nurse Root cause analysis is a process
than a disciplinary tool, and that organiza- leaders and others engaged in patient safety for identifying the basic or causal
tional culture, policy, and practice be properly work regularly inspect the work environment factor(s) underlying variation
aligned with this goal. Some organizations and observe and understand the processes in performance. Variation in
performance can (and often
have implemented anonymous incident report- involved in the work.
does) produce unexpected and
ing in order to alleviate staff fears and promote undesired adverse outcomes.
reporting. Reward systems that include prizes Lighting, noise, and clutter. It is important
and drawings as well as public recognition for to take into account the nurse’s physical work Root cause analysis is designed
reporting “good catches” can also be effec- environment, including lighting, noise, and to answer the following questions:
tive in encouraging staff to report errors and clutter. Poor lighting, such as that found in the • What happened?
close calls. In addition, many organizations room of a sleeping patient, and high levels • Why did it happen?
• What can be done to prevent
have implemented the principles of a culture of background noise, commonly associated
it from happening again?
of safety and a “just culture” (see Chapter with monitor alarms, are also features of the
1), which also emphasize the importance of nurse’s work environment that can contribute The outcome of the root cause
reporting and learning from errors. to error. Inadequately designed work space, analysis is an action plan that, if
particularly the clutter and lack of space fre- fully implemented, reduces the
Another important function of incident reporting quently found in medication rooms, is often risk of similar events occurring in
is to notify appropriate organizational leaders overlooked as a source of medication errors. the future.
that an adverse event has occurred and that Many organizations allocate minimal space to
patient harm has resulted. This enables nurse medication rooms and other areas that sup-
leaders and the risk management department port “back room” functions not visible to the
to ensure that there is an appropriate organi- patient. In so doing, they may actually be
zational response, including prevention of fur- contributing to errors caused by inadequate
ther harm to the patient, appropriate disclosure space. This type of work environment can also
to the patient and/or family, and fulfillment of lead to distractions during the performance of
regulatory reporting requirements. In addition, critical tasks—for example, when multiple staff
incident reporting of a harm-causing adverse members carry out similar tasks in close prox-
event frequently triggers internal investigation, imity, particularly if conversation, even needed
including root cause analysis. conversation, takes place. A nurse may over-
hear another nurse state a drug dosage aloud
Finally, incident reporting can provide valuable and may inadvertently incorporate that dosage
information about risks throughout the orga- into his or her own calculations and actions.
nization and can help pinpoint organizational
83
Nurse leaders (and other senior leaders)

should regularly tour their units and observe
the work environment. Considerations to keep By thinking about
in mind on such tours include the following: workarounds as a
• Is the environment generally quiet and symptom of system
orderly or noisy and chaotic? flaws rather than policy
• Are there ringing phones and extraneous violations requiring
conversations in the immediate area? direct correction
• Is there adequate lighting? through disciplinary
• Is there excessive clutter in the work space? responses, nurse
• Are there many individuals doing similar leaders can identify
tasks in close proximity? and eliminate root
• Is all necessary equipment available and in causes of medication
good working order? errors and avoid the
trap of responding
Work process and work flow. In addition to individually to
inspecting the general area in which the error repeated patterns
occurred, nurse leaders should also observe of error.
the actual medication administration process.
When doing this, leaders should ask them-
selves these questions:
• Is the process efficient and well designed? Other Sources of Information
• Are there steps in the process that can be Other sources of information about potential
eliminated? medication administration errors include the
• Does the individual have to take many following:
steps and visit many locations in order to • ADMs and smart pumps usage and excep-
execute the tasks in question? tion reports
• Are all necessary supplies located in the • Pharmacy department indicator reports
immediate area? • Performance improvement department
• Does the individual get interrupted or data and analyses
distracted while executing a critical task? • Pharmacy and therapeutics committee
• Is there “task saturation”—a high number minutes and analyses
of discrete tasks that must be performed • Reports or minutes of any other commit-
within a short period of time? tees that analyze medication usage
• Are staff members employing workarounds,
and if so, what is driving this? Risk Analysis and Investigation
In the error scenario described at the beginning To reap the benefits of medication error risk
of this chapter, a workaround was employed identification systems, nurse leaders must ana-
to compensate for a system flaw—missing lyze the information produced by such systems.
medication. By thinking about workarounds as Understanding the interplay of factors that pro-
a symptom of system flaws rather than policy duce medication errors enables nurse leaders
violations requiring direct correction through to identify and implement system changes to
disciplinary responses, nurse leaders can reduce the probability of recurrence.
identify and eliminate root causes of medica-
tion errors and avoid the trap of responding Given the volume of incident reports gener-
individually to repeated patterns of error. ated in many organizations, it may not be
84
possible for nurse leaders to personally inves- Using Post-Incident Debriefings

tigate each and every medication incident Another technique helpful in streamlining and
reported. For this reason, many nurse leaders jump-starting medication error investigations is
try to take shortcuts by having staff members post-incident debriefing. Although they do not
who were involved in errors write their own replace thorough investigations, debriefings
recollections and analyses of events. How- can be extremely valuable in determining what
ever, this approach is highly subjective and happened and why it happened before memo-
biased, and it typically does not yield informa- ries of the event fade. Post-incident debrief-
tion that advances understanding of how the ings are also useful in determining immediate
error occurred or how it may be avoided in steps to mitigate harm, prevent recurrence,
the future. Staff members usually lack knowl- and ensure a proper and timely response to
edge about how errors evolve and are often an incident.
too emotionally involved in the error to be able
to analyze what happened in an objective Elements of a post-incident debriefing. A
manner. post-incident debriefing can be led by a charge
nurse, a shift supervisor, or even a well-trained
Completing a thorough investigation of all staff nurse. Nurse leaders should develop a
reported incidents might not be possible, but script and/or checklist to guide the nurse lead-
nurse leaders can and should prioritize the ing the debriefing. The post-incident debrief-
events that they formally investigate. There ings should address the following questions:
are several mechanisms that can help to • What exactly happened?
reduce the burden of this process, includ- • What do we think caused the incident, given
ing electronic reporting systems with prepro- what we know right now? (See Chapter 1
grammed screens that ask specific questions for more on causes of medication errors.)
related to the type of incident being reported. • Is there any risk that this could happen
again, today, or tomorrow?
Investigating Incidents by Category • What do we need to do right now to
Aggregating and investigating incidents by prevent it from happening again, today, or
category is also useful in streamlining the tomorrow?
investigation process and has the added ben- • Has the physician been informed?
efit of revealing patterns and recurring causes. • Has the patient and/or family been
Appropriate categories can be identified by informed?
reviewing aggregate incident reporting data. • Has an incident report been completed?
The following are some categories to consider • Has appropriate documentation been
for this approach: entered in the medical record?
• Wrong-patient errors
• Wrong-medication errors Conducting a Thorough Investigation
• Wrong-time errors As mentioned, a post-incident debriefing does
• Wrong-dose or wrong-frequency errors not replace thorough investigation of a harm-
• Allergy-related errors causing event. Such investigations are needed
• High-alert medication errors, such as to understand what happened and why it hap-
hypoglycemics, anticoagulants, and pened and to guide appropriate follow-up
chemotherapy actions, including full and accurate disclosure
• Intravenous (IV) pump programming errors of the event to the patient and/or family, root
• Patient-controlled analgesia errors cause analysis, and any mandatory report-
ing to outside agencies. The nurse leader can
and should collaborate with other departments
85
as needed, including risk management, phar- errors, requires nurse leaders to first examine
macy, and biomedical engineering. the policy critically.
Elements of a thorough medication incident Assessment of the policy. This line of inquiry
investigation. A thorough medication incident should include an examination of the policy
investigation comprises at least the following: itself:
• Review of all documentation • Are the requirements necessary? That is,
• Interviews of the individuals involved do they serve a useful purpose in main-
• Inspection of the location where the inci- taining safety or achieving some other
dent occurred worthwhile organizational goal? Or do they
• Observation of the processes involved simply serve to add unnecessary steps to
• Inspection of the medications involved and an already complicated process?
their containers • Are the requirements burdensome? Does
Relevant Requirements • Inspection and sequestering of any equip- compliance with the policy require the
Joint Commission Medication ment involved, such as IV pumps and employee to make unreasonable efforts
Management (MM) Standard tubing or undesirable choices between conflicting
MM.07.01.03 states, “The
but equally important goals?
organization responds to actual
Documentation review should include the • Does the policy achieve the desired goal?
or potential adverse drug [or
medication] events, significant following: Does it merely prohibit unwanted behavior
adverse drug [or medication] • The medical record for all patients involved or does it produce the desired behavior? Is
reactions, and medication • Any faxed order sheets, including both it specific and actionable by the end user?
errors.” Joint Commission Inter- the original and the copy received in the • Is the necessary infrastructure in place
national Medication Manage- pharmacy to support policy requirements? Do staff
ment and Use (MMU) Standard • All medication labels and informational members who are expected to abide by
MMU.7.1 states, “Medication
inserts the policy have the resources necessary to
errors, including near misses,
• Any applicable logbooks comply?
are reported through a process
and time frame defined by the • Staff schedule and assignment sheets • Is the policy written in clear, concise, and
organization.” • Unit census with patients identified by unambiguous language that is easy to
name understand for all staff, including newly
• Relevant written policies and procedures hired and/or recently graduated nurses?
Is it easy to use under the most challeng-
Considering Potential for Error by Policy ing circumstances, such as when a nurse
Although health care leaders tend to view writ- is working alone on the night shift with few
ten policy as an error prevention strategy, in resources from which to draw?
some cases written policies can actually cre-
ate opportunities for error. In the error scenario Effective policies go beyond proscribing
presented at the beginning of this chapter, the unwanted behavior by removing obstacles to
nurse involved knowingly violated policy. It is desired performance. They make doing the
tempting to accept this at face value and sim- right thing easy and eliminate conflict between
ply discipline the nurse. A closer examination competing goals, such as adherence to safety
of the incident, however, reveals that the vio- practices and productivity.
lation occurred because the policy places the
burden of compensating for a poorly function- Conducting Interviews
ing system squarely on the shoulders of the As noted previouisly, a thorough investigation
nurse, who has many other competing pri- includes interviews with each individual involved
orities. Thus, effective management of policy in the medication error incident. The purpose of
violations, even those resulting in egregious the interview is not to discipline the individual,
86
but rather to gain a more complete understand- she saw and heard during his hospitalization.
ing of the events surrounding the incident. This clearly hampered the investigation. It is
critical that patients and their family members
Elements of the interview. The interview be included in the investigation of any incident.
need not be lengthy, but should include the fol-
lowing questions, at minimum: Post-Incident Evaluating of Work
• What exactly happened? (Have the indi- Environment and Work Processes
vidual recount the events in chronological Even when an interview is conducted imme-
order.) diately following an event, it usually tells only
• What were you doing when it occurred? part of the story. A complete picture of how an
(Have the individual describe the circum- event occurred usually requires nurse lead-
stances and surroundings when the ers to go beyond reviewing reports and inter-
incident occurred.) views to also visit the site where the incident
• Where you interrupted or distracted when occurred. The purpose of this site visit is to
this occurred? If so, please explain. identify environmental and work design fac-
• Had there been any unusual surges in unit tors that may have contributed to the error.
activity prior to the event? If so, please When examining the work environment and
explain. the work processes for clues as to how an
• Did you have everything you needed to error occurred, the nurse leader should con-
properly administer the medication? If not, sider the same questions mentioned in the
please explain. section, “Risk Identification” (see “Evaluating
• Did you encounter any particular difficulties Work Environment and Work Processes” on
when administering the medication? If so, page 84).
what did you do about it?
• When and how did you first become aware Inspecting Medication Storage
that an error had occurred? Inspection of medication storage, including
• Has the event occurred before? If so, what containers and packaging, is another key com-
caused it the last time? ponent of thorough investigation of medication
• What did you do immediately in response to errors, and it is one that will help to identify
the error? erroneous or confusing labeling that may have
• What has the patient been told? contributed to the error. Also, the problem of Relevant Requirements
look-alike/sound-alike (LASA) drugs can be Joint Commission Medication
Interviewing the patient and family. One identified through the inspection of medication Management (MM) Standard
critical aspect of any event investigation that packaging and containers. LASA drug errors MM.01.02.01 states, “The
is often overlooked is interviewing the patient have captured the attention of mainstream organization addresses the safe
use of look-alike/sound-alike
and family members, and even visitors, about media in addition to professional journals.
medications.”
what they may have seen or heard relative According to msnbc.com, such errors most
to an error that occurred. This point is well often involve pharmacy technicians, but reg-
illustrated in The Story of Lewis Blackman, a istered nurses are involved in up to 20% of
program in the educational video series “The these incidents. About 1,500 drugs have been
Faces of Medical Error . . . From Tears to identified as vulnerable to LASA–related con-
Transparency.”5 In this video, Lewis’s mother fusion.6 Accordingly, nurse leaders and others
described her constant vigil at her son’s engaged in patient safety work must be alert to
bedside while he bled to death, undetected the possibility that this factor may be involved
by caregivers. Despite the fact that Lewis’s in some of the medication errors they are
mother never left his bedside, hospital rep- investigating or attempting to prevent.
resentatives did not interview her about what
87
Inspecting and Sequestering Equipment

Finally, inspection and sequestering of equip-
Policy revision and
ment are vital to a thorough medication error
retraining of staff are
investigation. Unfortunately, this essential step
the most common
is often overlooked by both frontline nurses
organizational
and clinical leaders. All supplies and equip-
responses to error,
ment, including disposable items, in use at the
yet they are the
time that a medication error occurred should be
least effective.7
saved for examination. This means that nurse
leaders must work closely with risk managers
to ensure that frontline clinical staff, including
patient care assistants and housekeepers, Forcing Functions
are aware of this important step. In addition, The most effective risk-reduction strategy is
nurse leaders should work closely with the the use of forcing functions—work designs
DEFINED: Forcing Function
risk management and biomedical engineering that literally stop the process until the caregiver
A forcing function is an activity
that forces a person to do some- departments to determine whether equipment executes the correct next step. Constraints,
thing and produce a result. In is broken or defective, whether it needs to be which prevent an error from occurring but do
health care, forcing functions are sent out for independent testing, and whether not force the caregiver to execute the task cor-
work designs that literally stop reporting to the U.S. Food and Drug Adminis- rectly, are nearly as effective. Standardization,
the process until the caregiver tration (FDA) or other regulatory agencies is automation, and checklists are moderately
executes the correct next step. required. effective risk-reduction strategies, whereas
policies and procedures, staff training, and
Risk Reduction: Selecting the warnings are among the least effective.
Best Strategies
Using Double Checks and Avoiding
Policy revision and retraining of staff are the Confirmation Bias
most common organizational responses to It is important to note that double checks, a
error, yet they are the least effective.7 They are commonly used error prevention strategy, are
so frequently used, and overused, because recommended for only a short list of medica-
they require minimal effort, are generally inex- tion administration scenarios. To be effective,
pensive and “budget-neutral,” and create the each check step in the double-check process
illusion for executive leaders, boards, and reg- must be completed independently—that is,
ulators that the organization has done some- neither party can be allowed to bias the other
thing about an error. In fact, policy revision party’s calculations or perceptions. Thus, dou-
and staff retraining are extraordinarily expen- ble checks are effective when a nurse on a
sive for health care organizations over the patient care floor checks the work of the phar-
long term. Using these strategies to address macist or technician in the pharmacy who dis-
an error virtually guarantees that the error will pensed the drug. However, double checks are
recur, meaning that the staff time and organiza- less effective when two nurses working on the
tional resources consumed by the error itself, same unit at the same time check each other’s
as well as the time and resources required for work, and much less effective when a person
investigation and review, are wasted. All that checks his or her own work.7 Confirmation
effort will have failed to achieve the desired bias—seeing just what one expects to see—is
result: preventing the error from recurring. Fur- often the cause of the reduced effectiveness
thermore, the direct costs associated with the of double checks in such situations. Confirma-
error will be incurred repeatedly. tion bias played a role in the error scenario
88
presented at the beginning of this chapter. Applying Performance Analysis Tools

When the nurse borrowed the medication A very effective tool for analyzing problems
from the other patient’s cassette, she failed to with human performance was developed by
notice that it was a different dosage than she Mager and Pipe in Analyzing Performance
needed. It is possible, and even likely, that she Problems. They provide an algorithm for ana-
checked the dosage but, because of confirma- lyzing performance that helps managers better
tion bias, failed to notice that the medication understand the drivers of unwanted behavior
she was borrowing was the incorrect dose. (see Figure 4-1 on pages 91–92).
Confirmation bias also comes into play when Reasons for substandard performance.
nurses working together check each other’s Mager and Pipe also suggest that employees
work. A nurse double-checking a colleague’s fail to perform as desired for a variety of rea-
dosage calculation or the name of a high-alert sons, including the following10:
drug is often biased by the information already • They don’t know what’s expected.
presented by the colleague. Thus, the second • They don’t have the proper tools, space,
nurse sees what he or she expects and is or authority.
expected to see. In addition, double checks by • They don’t get feedback about perfor-
a second nurse are vulnerable to “halo effect” mance quality.
bias. If a nurse is asked to check the work of • They are punished when they do things
a highly respected or authoritative colleague, right.
that person’s reputation and perceived high • They are rewarded when they do things
level of competence may bias the reviewer, wrong.
causing him or her to overlook errors in the • They are ignored whether they do things
double check. Finally, performing a double right or wrong.
check correctly is time-consuming, and staff • They don’t know how to do things.
are often tempted to take shortcuts, such as
simply “eyeballing” the other person’s calcula- In the error scenario presented at the begin-
tions without actually manually performing the ning of this chapter, the nurse lacked the
required calculations. For these reasons, dou- proper tools to perform her assigned tasks
ble checks should not be widely used as an correctly—the correct medication was not
error prevention strategy. The Institute for Safe available when needed. Furthermore, doing
Medication Practices recommends that double the correct thing—calling the pharmacy for the
checks be reserved only for IV chemotherapy, medication, completing an incident report—
IV and epidural opioids, IV insulin, IV heparin, would have been punishing because it would
neonatal parenteral medications, TPN (total have caused her to fall behind in her work and
parenteral nutrition) compounding, and man- to fail to meet the patient’s expectations of
ual compounding of electrolyte solutions.8 If timely medication administration. Conversely,
double checks are used, diligent efforts must doing the wrong thing—simply borrowing the
be made to ensure that they are truly indepen- medication from another patient—was reward-
dent and free of bias introduced by the nursing ing, because it enabled the nurse to keep the
colleague whose work is being checked. patient satisfied by giving the medication on
time and to not fall behind in her work by tak-
Table 4-1 on page 90, based on the work of ing time to complete an incident report and call
Gosbee and Gosbee,9 summarizes the range the pharmacy.
of risk-reduction strategies available to nurse
leaders working to reduce or eliminate medi- Mager and Pipe do not dismiss the impor-
cation errors. tance of training or discipline in managing
89
TABLE 4-1. Medication Error Risk-Reduction Strategies Available to Nurse

Leaders
Effectiveness Objective Category Examples

Prevention—reduces or Forcing functions CPOE system requiring that patient
eliminates probability of weight be entered before the medi-
error cation order entry can proceed
High
Constraints Free-flow protected IV pumps, epidu-
ral catheters without injection ports
Detection leading to Standardization, Medication available in only one con-

correction—makes errors automation centration, point-of-care bar coding
more visible and easy to
Moderate Checklists and Preprinted order sheets for MI,
spot and correct
protocols, double stroke, postpartum care
checks
Detection only—mitigates Rules and policies Medication administration policy

consequences of error only
after it has occurred Training, Mandatory annual retraining,
Low information, newsletters
warnings
KEY: CPOE: computerized provider order entry; IV: intravenous; MI: myocardial infarction.
Source: Gosbee J.W., Gosbee L.L. (eds.): Using Human Factors Engineering to Improve Patient Safety. Oakbrook Terrace, IL:
Joint Commission Resources, 2005.
performance. Instead, they advocate using characteristics of the individual staff member
the appropriate intervention to manage perfor- involved in an error contributed to it. Appre-
mance problems, based on a thorough under- ciating contextual information related to indi-
standing of the causes of the substandard viduals does not necessarily conflict with a
performance. If the cause of the performance systems approach to safety. For example, a
problem is an organizational obstacle to the nurse leader may find that a nurse’s difficulty
desired behavior, the appropriate intervention with the English language contributed to a
is to remove the barrier. This is the underlying medication error. Although this may have been
problem to be solved. a factor in the event, it is not likely the root
cause of the event. Thus, the nurse leader
Considering Individual Staff Members’ would continue the inquiry until the underlying
Characteristics system cause is identified.
Although a foundational principle of patient
safety is a focus on systems rather than Factors to screen for. Factors to consider
people, there are instances in which the when determining whether an individual staff
90
FIGURE 4-1. Performance Analysis Flowchart
Source: © 1997 The Center for Effective Performance, Inc. Adapted from Mager R.F., Pipe P.: Analyzing Perfor-
mance Problems, 3rd Ed., Atlanta: Center for Effective Performance, 1997. For information, contact: The Center
for Effective Performance, Inc., Atlanta, Georgia, 1-800-558-4CEP, or visit www.cepworldwide.com. Reprinted
with permission.
(continued)
91
FIGURE 4-1. Performance Analysis Flowchart (continued)
Source: © 1997 The Center for Effective Performance, Inc. Adapted from Mager R.F., Pipe P.: Analyzing Perfor-
mance Problems, 3rd Ed., Atlanta: Center for Effective Performance, 1997. For information, contact: The Center
for Effective Performance, Inc., Atlanta, Georgia, 1-800-558-4CEP, or visit www.cepworldwide.com.
Reprinted with permission.
member’s characteristics contributed to a • Did cultural factors or language barriers

medication error include the following: play a role?
• Was this a new employee with perhaps • Was the individual under the influence of
insufficient training or experience for the drugs or alcohol?
work assigned?
• Was illness or emotional distress a factor?
92
• Was fatigue a facto, that is, was the individual implementing change.14 This model, which is
working overtime or was he or she suffering straightforward and easy to follow, has been
from sleep deprivation from other sources? shown to be successful in driving complex and
organizationwide change. Kotter’s model con-
Fatigue. Research has shown a clear rela- sists of the following eight steps:
tionship between fatigue among nurses and
increased errors.11–13 Nurses suffering from Step 1. Create a sense of urgency. To do
fatigue have significantly decreased levels of this, leaders must make a clear and convinc-
alertness and vigilance. In addition, fatigue ing argument about why the change is needed.
decreases nurses’ ability to perform techni- Nurse leaders can best make this argument by
cal tasks, such as IV insertion, and reduces sharing with staff information about medication
clinical decision-making ability. Speed and errors and their causes and by leading an open
accuracy of work also suffer in the presence and honest dialogue with staff on the impact
of fatigue, as do communication skills. The such errors have on patients, staff, and the orga-
effects of fatigue were also seen in nurses nization as a whole. This conversation must be
working shifts of 12 hours or longer. In gen- conducted not only with frontline staff, but also
eral, mandatory overtime, working double with the entire leadership team. According to
shifts, working longer shifts, and working two Kotter, 75% of the organization’s leaders must
or more jobs all contribute to fatigue among support the change for it to succeed. Therefore,
nurses, and this should be considered when- nurse leaders must be prepared with good data
ever health care managers analyze causes of and meaningful information and analysis about
seemingly simple errors. the impact of medication errors in order to lead
these conversations with both frontline staff and
Implementing Risk-Reduction organizational leaders.
Strategies
Successful implementation of risk-reduction
According to
strategies relies heavily on changing human
Kotter, 75% of the
behavior and organization culture. These
organization’s leaders
changes are difficult to achieve and even
must support the
harder to sustain. The health care industry has
change for it to succeed.
undergone substantial changes over the past
decade, and health care reform, combined
with shrinking resources, promise that the vol-
ume and pace of change will only accelerate. Step 2. Form a powerful coalition. Con-
In addition, many of the risk-reduction strate- vincing people that change is needed is dif-
gies that are most likely to be effective require ficult without the support of key people who
broad organizational and financial commit- influence the opinions of others. Nurse lead-
ment. For these reasons, it is imperative that ers should identify a group of key people
health care leaders develop the skills neces- with influence emanating from their job titles,
sary to drive and sustain change. expertise, or political power in the organiza-
tion. This group should include at least some
Kotter’s Model for Implementing Change physicians as well as pharmacists and other
John Kotter, a world-renowned expert on influential clinicians. In addition, nurse manag-
change management and a professor in ers should consider including the CFO or other
the Harvard School of Business, has devel- representative from the finance department
oped an eight-step model for successfully because penalties for errors from third-party
93
payers are increasingly common and can help work to align policies, job descriptions, and
make the business case for change. other written materials with the change vision.
It is helpful to recognize and reward those who
Step 3. Create a vision for change. This embrace the change, and identify and con-
will help people understand why the change vince those who don’t. Redesigning processes
is needed and remind them of why they are or the environment may be needed to support
engaged in this effort. Nurse leaders should the desired change. For example, if a nurse
appeal to the shared values of the change leader wants to increase error reporting, he
coalition, and the organization more broadly, or she must provide an error reporting system
to create this vision. This step also involves that is easy to use and easily accessible to
creating a change strategy. Kotter suggests staff.
crafting a short statement (one or two sen-
tences) that captures the vision for the future Step 6. Create short-term wins. Success
as a result of this change. This short state- is a powerful motivator, and visible results
ment can then be used by each member of reinforce those who support the change and
the guiding coalition to spread the message to thwart detractors. Starting with smaller goals
the rest of the organization. The following is a that are more easily attainable, such as elimi-
sample vision statement for medication error nating wrong-patient errors for one month, is
reduction: “Medication errors are injuring ___ advised, with gradual expanding of the tar-
patients in our organization every year, and get and plans for successive victories and
they cost our organization ___ dollars. Nurse rewards. Kotter suggests that early goals
leaders need to be able to reassure patients should be inexpensive so as not to frighten off
and all stakeholders that the organization can people who might otherwise be supporters.
consistently and reliability deliver the right
medication to the right patient at the right time Step 7. Build on the change. One of Kot-
without causing anyone injury.” ter’s key points is that many change efforts fail
because victory is declared too soon. Quick
Step 4. Communicate the vision. Nurse wins are gratifying and a good way to start, but
leaders should talk about the vision whenever real and lasting change requires more effort.
possible, not just at meetings. They should Leaders must continue to nurture the effort
incorporate it into their daily work, such as and reward successes well beyond the early
planning and problem solving. They should talk wins. This means analyzing each success to
open and honestly with others about their con- determine what worked and what didn’t and
cerns, and lead by example. If a nurse leader incorporating those lessons into future change
wants to improve medication error reporting by efforts.
fostering a culture of safety, that leader should
approach all discussions about medication Step 8. Anchor the changes in organiza-
errors in an open and nonjudgmental manner. tional culture. Leaders should make success
That vision for change should also be incorpo- visible throughout the organization by talking
rated into training programs and performance constantly about progress. They should share
reviews. measurement data and tell success stories.
They must also incorporate change ideals and
Step 5. Remove obstacles. Identifying and values into hiring practices and publicly rec-
removing barriers that stand in the way of the ognize those who helped make it happen. As
change envisioned is vital. If possible, nurse change leaders transition or move on, they
leaders should make use of change agents should be replaced with others who share the
from within the organization. They must also enthusiasm.
94
Performance Feedback of success. However, this is a highly unreliable

In addition to Kotter’s eight-step change man- indicator of success for several reasons. Com-
agement program, another key component pliance with reporting is usually very low, with
of successful change management is per- only a small fraction of actual events being
formance feedback. This requires that nurse reported via incident reporting systems. Also,
leaders be vigilant about monitoring the prog- incident reporting compliance by staff is highly
ress of change and that they provide positive vulnerable to the “Hawthorne effect”: Staff ini-
feedback as well as negative feedback to tiate reports when they know that a particular
those attempting to adopt the change. Such problem is being studied or when they want to
feedback needs to be timely and objective and make sure that a particular problem is studied.
Relevant Requirements
should be specific enough either to reinforce Also, using declining incident reporting rates
Joint Commission Performance
existing good practice or to modify poor prac- as a measure of success may have the unin-
Improvement (PI) Standard
tice. The difference between bad feedback tended consequence of dissuading staff from PI.03.01.01 for hospitals
and good feedback is comparable to the differ- reporting close calls. states, “The hospital improves
ence between “Mary, you’re doing great; keep performance on an ongoing
up the good work” and “Mary, you consistently Regardless of the measurement strategy used, basis.” For other accreditation
check two patient identifiers before adminis- it is critical that measurements be continued programs, the standard states,
tering medications, and you always administer long enough to ensure that the organization “The organization improves
performance.”
your medications accurately and on time.” isn’t declaring victory too soon. At a minimum,
measurement should continue for a period of
Monitoring and Modifying Risk- six months, and longer periods may be nec-
essary if the risk-reduction strategy being
Reduction Strategies
monitored addresses an error that occurs very
Sustaining risk-reduction strategies requires rarely. Following the initial period of measure-
careful monitoring of the outcomes of the ment, monitoring should be repeated at regu-
changes and modification of the strategies as lar intervals to ensure ongoing effectiveness
needed to achieve the desired result. Monitor- and adoption of the change.
ing can take a variety of forms and in many
cases requires collaboration with other depart- Conclusion: A Call to Action
ments such as risk management, performance
improvement, or pharmacy. Although most errors in health care are com-
plex and involve the interplay of many factors,
Techniques to gauge success. The following nurse leaders should not abandon all hope
are some monitoring and measurement tech- of intervening in a meaningful way after an
niques that can be used to gauge the success error occurs. On the contrary, the complexity
of risk-reduction strategies: of errors makes the role of the nurse leader
• Medical record reviews in responding to errors all the more essential,
• Direct observation provided that the nurse leader takes the time
• Staff assessment to understand the causes of the error and to
• Data reports from electronic medical record plan the intervention accordingly. This does
systems not mean that a root cause analysis must be
• Variance and exception reports from ADMs completed after each and every error and
or smart pumps before any action is taken. It does, however,
• Staff self-assessments or surveys require health care managers to resist easy,
“one-size-fits-all” solutions to complicated
Many nurse leaders and risk managers attempt problems.
to use incident-report frequency as a measure
95
Nurse leaders who take the time to understand Management Handbook for Healthcare Orga-
the true system causes of errors recognize nizations, 6th ed., vol. 1: The Essentials. San
that neither training nor discipline are effec- Francisco: Jossey-Bass, 2011.
tive strategies for overcoming such causes 4. Head G.L., Horn S.: Essentials of Risk Manage-
of human errors. These leaders would resist ment, 3rd ed., vol. I. Malvern, PA: Insurance
the temptation to implement simple solutions, Institute of America, 1997.
such as double checks. Enlightened health 5. Transparent Health: The Story of Lewis Black-
care leaders who understand the complexity man. The Face of Medical Error . . . From Tears
of error also understand that the best hope for to Transparency Series [DVD/CD]. Chicago:
truly eliminating error rests with proper design Transparent Learning, 2010.
of work processes. Knowing what strategy 6. Aleccia J.: Look-Alike, Sound-Alike Drugs
to use when is critical to the success of the Trigger Dangers: 5 Million Errors a Year Tied to
error prevention initiative. This requires an in- Wrong Medications; Some Cause Injury, Death.
depth understanding of the mechanisms that MSNBC, updated May 28, 2010.
resulted in the error, information that is not
http://www.msnbc.msn.com/id/37386398/ns/
readily obtainable from the review of incident
health-health_care/t/look-alike-sound-alike-
reports alone.
drugs-trigger-dangers/ (accessed May 9, 2011).
7. Wu A.W., Lipshutz A.K., Pronovost P.J.: Effec-
Nurse leaders must move beyond cursory
tiveness and efficiency of root cause analysis in
reviews of incidents and generic strategies to
medicine. JAMA 299:685–687, Feb. 13, 2008.
achieve a deep understanding of the genesis
8. Institute for Safe Medication Practices: Santa
of errors and the factors that affect human
checks his list twice. Shouldn’t we? ISMP Medi-
performance. Nurse leaders who ignore these
important concepts—relying instead on stan- cation Safety Alert!, Acute Care Dec. 17, 2009.
dardized, simplistic rules to prevent errors—are http://www.ismp.org/newsletters/acutecare/
doomed to a cycle of repeated errors because articles/20091217.asp (accessed Jun. 24, 2011).
their interventions are unlikely to correct the 9. Gosbee J.W., Gosbee L.L. (eds.): Using Human
underlying system flaws that cause errors. Factors Engineering to Improve Patient Safety.
Worse, failure to correct systemic flaws under- Oakbrook Terrace, IL: Joint Commission
mines confidence in and support of the organi- Resources, 2005.
zation’s safety program by staff and, ultimately, 10. Mager R.F., Pipe P.: Analyzing Performance
by the patients the organization serves. Knowl- Problems, 3rd ed. Atlanta: Center for Effective
edge of the factors that contribute to error can Performance, 1997.
help the nurse leader design and implement 11. Owens J.A.: Sleep loss and fatigue in healthcare
work processes and interventions in response professionals. J Perinat Neonatal Nurs 21:92–
to errors that can really prevent recurrence and 100, Apr.–Jun. 2007.
keep patients safe from harm. 12. Rogers A.E., et al.: The working hours of hospi-
tal staff nurses and patient safety. Health Aff
References (Millwood) 23:202–212, Jul.–Aug. 2004.
1. National Patient Safety Foundation: 13. Scott L.D., et al.: Effects of critical care nurses’
3 Strikes and You’re Educated. work hours on vigilance and patients’ safety. Am
http://listserv.npsf.org/SCRIPTS/ J Crit Care 15:30–37, Jan. 2006.
WA-NPSF.EXE?A1=ind0605&L=patient safety- 14. Kotter J.P.: Leading Change. Boston: Harvard
L#1 (accessed May 10, 2011). Business School Press, 1996.
2. Leape L.L: Error in medicine. JAMA 272:1851–
1857, Dec. 21, 1994.
3. Carroll R., Nakamura P.L.B. (eds.): Risk
96
FOCUS: Technology
FOCUS
TecHNOLOGY:
Using Telepharmacy and PIS to Reduce Risks for Medication Error in
Critical Access Hospitals and Rural Hospitals
Pharmacy hours of operation are often more limited in critical access hospitals than in larger
hospitals, yet all critical access hospitals must have pharmacy services with a pharmacist over-
seeing the program. When pharmacists are not readily available to review medication orders
in a timely manner, there is an increased risk for prescribing errors, unauthorized drug errors,
and improper dose/quantity errors, most of which reach the patient because a pharmacist was
not available to prevent the error.1,2 In addition, the requirement to evaluate the medication
order for appropriateness is passed on to another individual—sometimes a nurse—who will
most likely not have the same expertise as a pharmacist to be able to question the purpose,
dose, or route of the prescription or to consider the risks of the medication in the context of
the patient’s other medications, allergies, diseases, or organ function.3 The Joint Commission
requires that this evaluation be performed by an individual who is competent to do so.
Nurses also have to take on the additional role of obtaining medications from the medication
storage area in critical access hospitals and rural hospitals when pharmacists are not on site.
Despite the fact that a nurse is not licensed to dispense medications, he or she must select the
right medication, the right amount of the medication, and the right form of the medication
when a pharmacist is not present.4 Research has shown that nurses are more likely than phar-
macists to choose the wrong medication because they are not as familiar with the pharmacy
inventory and the subtle pharmacological differences between medications.5 Finally, when
pharmacists or pharmacy technicians are not available 24 hours a day, nurses must also per-
form sterile product compounding. And a survey of critical access hospitals in Florida found
that nurses are not always reliable in adhering to protocols or using aseptic technique when
compounding medications.6
Furthermore, the survey of Florida critical access hospitals found that nurses did not always
check for drug allergies prior to administering medications, and they also had limited access to
information on cross-allergies to medications.6 Nurses almost always perform the final check
in the medication management system because they are usually the health care providers who
actually administer the medication; in critical access hospitals, nurses must realize that this
final check is even more critical when a pharmacist has not previously checked the medication.
Technology can support organizations with pharmacists who must make the most of their lim-
ited hours on site. It can also allow pharmacists working off-site during after-hours to have all
the patient and medication information they would usually have on site when reviewing medi-
cation orders. In addition to computerized provider order entry (CPOE), bar code medication
administration (BCMA), electronic health records (EHRs), electronic medication administra-
tion records (eMARs), and automated dispensing machines (ADMs; all discussed in Chap-
ter 2), when there are funds available, critical access hospitals should consider implementing
97
FOCUS
TecHNOLOGY:
Critical Access Hospitals and Rural Hospitals (continued)
(together or individually) the technologies described below to improve medication manage-
ment process.
Pharmacy Information Management System

The pharmacy information management system (PIS) technology provides clinical decision
support based on the patient’s profile (including sex, age, weight, height, allergies, laboratory
results, and other medications prescribed) and screens for drug–drug and drug–disease interac-
tions, drug admixture incompatibilities, drug–allergy interactions, and inappropriate doses.5
The PIS should be available to off-site pharmacists and nurses when pharmacists are not on site
so that patients can benefit from the safety features of this technology at all times of the day.5
Telepharmacy
Telepharmacy involves registered pharmacists remotely providing pharmacy care to patients or
hospitals through telecommunications or other technologies (such as fax machines).7 When
telepharmacy works in concert with other technologies, it is the most streamlined approach
to offering remote pharmacy services because the rest of the patient’s information is readily
available to the remote pharmacist. Although no specific data are being collected, critical access
hospitals using telepharmacy have reported reduced medication error rates.7
It is important to note that, depending on the critical access hospital’s location, there may be
rules and regulations regarding telepharmacy, particularly regarding local licensure of phar-
macists.7 In 2006 the National Association of Boards of Pharmacy revised the Model State
Pharmacy Act and Model Rules of the National Association of Boards of Pharmacy to states for
creating their own laws and regulations regarding remote pharmacies and remote dispensing
sites when appropriate.7 Critical access hospitals should check their state pharmacy act or other
applicable state laws and regulations to ensure that they choose a remote pharmacy that is
acceptable. In some states, there may not be any state regulations regarding remote pharmacies,
or the regulations may make it difficult to use a remote pharmacy. More states are enacting
legislation regarding remote pharmacies, which may encourage increased implementation of
telepharmacy in critical access hospitals and other rural hospitals.7
Telepharmacy Models
There are several different models for telepharmacy, including the following7:
• A larger hospital with round-the-clock pharmacist staffing reviews medication orders (sent
electronically or via fax) from smaller rural hospitals within the area. All these hospitals may
or may not be part of the same health care system. When they are, the organizations may
benefit from having the same computer software.
98
FOCUS: Technology
FOCUS
TecHNOLOGY:
Critical Access Hospitals and Rural Hospitals (continued)
• Small rural hospitals contract with a commercial telepharmacy company.
• Several small rural hospitals contract together for pharmacy services.
For more information on implementing a telepharmacy program, see guidance from the
American Society of Health-System Pharmacists (ASHP) at http://www.ashp.org/DocLibrary/
BestPractices/AutoITGdlRMOP.aspx.
References
1. Casey M.M., Moscovice I.S., Davidson G.: Pharmacist staffing, technology use, and implementation of
medication safety practices in rural hospitals. J Rural Health 22:321–330, Fall 2006.
2. American Hospital Association, American Society of Health-System Pharmacists, Hospitals & Health
Networks: Medication Safety Issue Brief: Small and rural hospitals—unique challenges, unique solutions.
Hosp Health Netw 79:45–46, Nov. 2005.
3. Wakefield D.S., et al.: A network collaboration implementing technology to improve medication
dispensing and administration in critical access hospitals. J Am Med Inform Assoc 17:584–587, Sep.–Oct.
2010.
4. Jones K.J., et al.: Study findings and trends in medication error reporting from 25 Midwestern critical
access hospitals. USP Patient Safety Capslink. U.S. Pharmacopeia Center for the Advancement of Patient
Safety, Jul. 2007. http://www.usp.org/pdf/EN/patientSafety/capsLink2007-06-01.pdf (accessed Apr. 3,
2011).
5. Hartzema A.G., et al.: Planning for pharmacy health information technology in critical access hospitals.
Am J Health Syst Pharm 64:315–321, Feb. 2007.
6. Winterstein A.G., et al.: Medication safety infrastructure in critical-access hospitals in Florida. Am J
Health Syst Pharm 63:442–450, Mar. 1, 2006.
7. Casey M., et al.: Implementation of Telepharmacy in Rural Hospitals: Potential for Improving Medication
Safety. Upper Midwest Rural Health Research Center, Dec. 2008. http://www.uppermidwestrhrc.org/
pdf/report_telepharmacy.pdf (accessed Aug. 10, 2011).
99
CHAPTER FIVE Medication SAFETY:
Considerations for Pediatrics
AUTHOR: Ronda G. Hughes, Ph.D., M.H.S., R.N., F.A.A.N., Associate Professor, Marquette University, Milwaukee
Medication errors have a higher chance of

exacerbating morbidity and mortality in pediat- Also, pediatric
ric patients.1 Children are uniquely vulnerable patients have a higher
to harm from medication errors for a number of likelihood of death
reasons. This chapter will provide information after medication errors
about the nature and scope of pediatric medi- than adults.
cation errors, particularly those related to the
safe administration of medications, and ways
in which nurses can reduce errors. Nurses, Although the full extent of the incidence and
as frontline caregivers, are well positioned to prevalence of pediatric medication errors is not
prevent medication errors from harming this known,5–9 medication errors affecting children,
vulnerable patient population. including medication administration errors, are
a worldwide concern.10,11 And although more
The Nature and Scope of pediatric medication errors are associated with
ө
prescribing/ordering (usually dosing errors),12
Pediatric Medication Errors
medication errors associated with administra-
Why are children so vulnerable? Pediatric tion are generally linked with nursing practice
patients are at significant risk for potentially or parents’ administering medications to their
harmful medication errors because medications child. Because nurses (and in some instances,
can exacerbate the symptoms of their mor- parents and other health care providers) are the
bidities1 and their renal, immune, and hepatic last potential barrier a child has to avert harm
functions may not be fully developed.2 Com- from a medication error before and while a
pared with adults, pediatric patients have three medication is being administered, they must be
times the relative risk of suffering an adverse well informed about that child’s medication(s).
drug reaction,3 particularly when medications Specific actions and targeted recommendations
are used differently than indicated,4 a common for parents that nurses can provide, emphasiz-
practice in pediatrics. Challenges in prescribing ing clear communication and patient and family
and dosing are compounded by the paucity of education, are described in Table 5-1 on page
pharmacokinetic and pharmacodynamic data 102. (See the Focus feature on page 109 for
for medications that can be used in the pediatric more on parents’ administration of medication to
population because the vast majority of medi- children, specifically in ambulatory health care.)
cations were developed for and tested in adult
populations (see page 113 in Chapter 6 for defi- Factors Associated with Pediatric
nitions of pharmacokinetics and pharmacody- Medication Administration Errors
namics). Also, pediatric patients have a higher The complexities of caring for children offer
likelihood of death after medication errors than additional possibilities for medication errors.13,14
adults.1 Medication ordering and administration are
101
TABLE 5-1. The Agency for Healthcare Research and Quality’s Tips to Help
Parents Prevent Medical Errors in Children
What Parents Need to Know Related Targeted Recommendations

to Their Child’s Medications
The child’s weight and the child’s Make sure all your child’s physicians know about everything your
prescribed pharmaceuticals child is taking and his or her weight. This includes prescription
and over-the-counter medicines and dietary supplements such as
vitamins and herbs.
The child’s known drug allergies Make sure your child’s physician knows about any allergies and
how your child reacts to medicines.
Exactly what the prescription states When your child’s physician writes you a prescription, make sure
you can read it.
If your child is getting the right medica- When you pick up your child’s medicine from the pharmacy, ask,
tion at the right time Is this the medicine that my child’s physician prescribed?
The purpose of the medication and its Ask for information about your child’s medicines in terms you can
recommended administration protocol understand—both when the medicines are prescribed and when
you receive them at the hospital or pharmacy.
Directions for proper medication If you have any questions about the directions on your child’s
administration medicine labels, ask.
Correct dispensing device Ask your pharmacist for the best device to measure your child’s
liquid medicine. Also ask questions if you’re not sure how to use
the device.
Possible side effects to the medication Ask for written information about the side effects your child’s
medicines could cause.
Source: Agency for Healthcare Research and Quality (AHRQ): 20 Tips to Help Prevent Medical Errors in Children: Patient Fact
Sheet. AHRQ Publication No. 02-P034, Sep. 2002. http://www.ahrq.gov/consumer/20tipkid.htm (accessed Mar. 27, 2007).
very different for infants and children than dosing.4 Doses must be constantly calculated,
for adults. Pediatric patients are prescribed recalculated, and adjusted according to the
fewer drugs than adults, but, as noted, are at child’s weight and must also take into account
a disproportionately higher risk of medication age (for age-appropriate dose determination),
errors due to several factors.9 developmental changes, and body surface
area18,19 (for body surface area calculations),
Dose calculations. Drug preparation, pre- as well as adjusted for the various concen-
scribing, and administration are more complex trations and formulations of medications.20
in children. Because the majority of medica- As children age, the calculated milligram-per-
tions are developed, licensed, and formulated kilogram (mg/kg) dose can even exceed maxi-
for adults15,16 and there are few pediatric- mum dosing limits.2 Although mg/kg dosing
specific standardized dosing regimens17 that might exceed maximum dosing limits, pre-
take into account the physiological changes, scribers and others should know that doses
maturation, and differences, as well as the must not exceed adult doses or maximum
variations in the size of a child, prescribers doses. Each calculation is an opportunity for
have to carefully judge and calculate drug a dosage error if there is a misplaced decimal
102
CHAPTER FIVE: Medication Safety: Considerations for Pediatrics
point (which can result in 10-fold errors21), medications prescribed for children,27 and lack
incorrect or misread fractional dosing (for of standardized communication of dispensed
example, mg versus gm) or trailing zeros, or doses for administration, such as “unit dose”
a child’s weight is inaccurately converted from or “unit of use” containers.28
pounds to kilograms (or if pound weight is con-
fused with kilogram weight). Because of these Key implications for nursing practice. To
challenges, efforts to improve availability and address these factors, there are several key
access to safe, child-specific medicines for implications for nursing practice:
children are under way throughout the world11 • Before administering a prescribed medica-
to avoid the need to convert adult-specific tion, nurses need to understand pediatric drug
doses to therapeutic dosages for children. calculations for dosing and to double-check
the calculations made by the prescriber.
Lack of skills. Pediatric medication errors • Nurses need to know the current weight
have been attributed to a lack of knowledge of the child in kilograms and to check
and skills,22,23 particularly poor mathematical that the dosage is appropriate, given the
skills24,25 that are necessary for correct dos- child’s weight, before any medication is
ing calculations. Medication errors associated administered.
with drug prescribing and administration have • Nurses administering medications to chil-
also been attributed to poor communication dren need to have current knowledge of
and lack of teamwork skills among health care each medication and possible adverse
providers.12 effects prior to use by their patients.28
• It is important that policies and proce-
dures are in place and being followed
that eliminate the risk of administering the
Pediatric medication wrong medication in the wrong dosage at
errors have been the wrong time to the wrong child. (See
attributed to a lack “Institutionalize Organizational Medication
of knowledge and Policies” on page 104.)
skills,22,23 particularly • Organization leadership needs to be very
poor mathematical supportive of a culture of safety to enable
skills24,25 that are nurses to administer medications under
necessary for correct the best possible circumstances and feel
dosing calculations. enabled to report potential risks for medi-
cation errors. (For more information on a
culture of safety, see Chapter 1.)
• Standardized dosing ranges should be
Organizational factors. Medication adminis- available, and nurses should check all
tration errors are more frequently wrong-time medication orders against the ranges.
errors that result from organizational factors,26
such as not having the right training on pediat- Preventing Medication Errors in
ric medications or the complexity of the many
steps involved in the medication administra-
Children
tion process. Other organizational factors that Several strategies have been used success-
may increase the risk of adverse medication fully to improve medication safety for children,
administration errors in children are lack of ranging from improving information utilization
pediatric-specific formulations and standard- to improving sharing and communication.
ized labeling and packaging for all types of
103
Gather Patient Information and Apply • Limiting storage of vials of high-concen-

Current Knowledge tration medications (for example, heparin
Caregivers should know the patient’s param- 10,000 units per milliliter) to the pharmacy
eters (for example, the child’s weight in kilo- • Mixing and dispensing of infusions from the
grams, age, and health history). Information pharmacy
Sentinel Event Alert 39 on each medication before it is administered, • Having pharmacy prepare all patient-
The Joint Commission Sentinel including what is considered a safe dosage, specific doses, unless these are needed
Event Alert 39, “Preventing Pedi- why the medication is being prescribed, and urgently
atric Medication Errors,” outlines • Using double checks in both the pharmacy
what the possible side effects are is critical
pediatric-specific strategies for and in nursing units,29 particularly if there
to keeping children safe. For example, physi-
reducing medication errors,
cians and nurses should communicate (ver- are unusual volumes or doses or concerns
including using technology
judiciously. Other Sentinel Event bally and in writing) the child’s weight using from the parent and/or patient30
Alerts that address pediatric only kilograms. • Including patient’s weight (in kilograms)
medication errors include Issues and height on all medication orders
11, 12, and 13. Given the diversity of available pharmaceuti- • Clearly labeling and storing look-alike/
cals, the sensitivity of children to the effects sound-alike medications separately29
of pharmaceuticals, and the possibility of off- • Using oral syringes to ensure correct dosage
label uses, nurses must make certain process of oral liquid preparation medications28
checks before any medication is administered
to a child (see Table 5-2 on page 105). Along with policies on these topics, it is important
to have policies and procedures for the medica-
Use Information Technology tion administration process and to monitor for
Information technology, when available, any deviations from policies and best practices
accessible, and interoperable, can decrease that can result from heavy workloads.31 Also,
medication errors when it improves commu- nurses must make certain to check the pre-
nication and decision making and when it is scribed and calculated dosage before any medi-
Joint Commission Medication used in addition to nursing monitoring and cation is administered to a child.28
Management (MM) Standard care. (For more information on how technol-
04.01.01 states, “Medication ogy can help nurses ensure medication safety, Enhance Communication Processes
orders are clear and accurate.” see Chapter 2.) Strategies to improve how and when clinicians
communicate about medication safety and
Institutionalize Organizational potential errors are important as well. Under-
Medication Policies standing potential errors or close calls may
Organizations should consider implementing provide key information on how future medi-
several policies to improve medication order- cation errors for this particularly vulnerable
ing and administering for pediatric patients. population can be averted. Because nurses
The topics addressed should include the may underreport medication errors in fear of
following: reprisal or from uncertainty about what consti-
• Dose limits within the computerized provider tutes a medication error, organizations need
order entry (CPOE) decision support for to have nonpunitive reporting processes in
each high-alert medication prescribed for a place to encourage error reporting, regardless
child (see Table 5-3 on page 106) of patient harm. (For more information on risk
• Standard doses and concentrations for management related to medication errors, see
commonly used medications in children28 Chapters 1 and 4.) Even when there has been
• Standard recipes for medications needing no specific reprisal, the fear and grief when
dilution used by pharmacists to avoid the a medication error has harmed a child in any
need to dilution at the bedside way can be devastating to a nurse.
104
TABLE 5-2. What to Do Before Giving Any Medication to a Child
Type of Medication What to Check

Common, child-approved medications (for example, antibiot- • Name and purpose of the medication
ics, antipyretics) • Name of child to receive the medication
• Any drug allergies or sensitivities
• Weight of the child (in kilograms) and ap-
propriate, safe dosing range
• Policies and procedures for safe medica-
tion administration
Off-label medications (for example, immunosuppressive • Verify with the individual prescribing the
medications, cancer medications, cardiac medications) medication the medication name, the pur-
pose for which it is to be used, its dosage,
and the duration it will be administered
• Double-check dosage (if child is less than
40 kilograms, the dosage should be less
than that of an adult dosage)
• Possible drug–drug interactions and/or
adverse reactions to be vigilant for while
monitoring the child Relevant Requirements
• Response of the child to the medication The Joint Commission’s National
following administration Patient Safety Goal 2 states, “Im-
prove the effectiveness of com-
munication among caregivers.”
Joint Commission International’s
Source: Conklin D., et al.: Medication errors by nurses: Contributing factors. AARN News Lett 46:8–9, Jan. 1990; Stucky E.R.,
American Academy of Pediatrics Committee on Drugs, American Academy of Pediatrics Committee on Hospital Care: Prevention of International Patient Safety
medication errors in the pediatric inpatient setting. Pediatrics 112:431–436, Aug. 2003. Goal 2 states, “The organization
develops an approach to improve
the effectiveness of communica-
Communication during transitioning and hand- It is important to continuously ensure and tion among caregivers.”
offs can be a time when medication errors occur. improve communication with children, their
Communicating with another clinician/health care parents, and other family members. Nurses
team, even when handing off a pediatric patient are often in the best position to provide edu-
to the next shift or another clinician, requires cation with sufficient detailed explanations
clear communication without distractions and and rationales so that the child receives age-
interruptions. In the health care setting there are appropriate explanations and the family can
many distractions. It is easy to not communicate adequately understand the medication. This
key pieces of information, such as what medica- information can be best conveyed verbally
tions are being given and at which dose. Nurses and in writing. Education can be furthered
can easily make a “slip” because they are doing by nurses observing and providing feedback
several things at the same time, can be inter- to the child and family while they practice the
rupted to help another child or their family, or can proper drug administration technique. Nurses
forget to say something without having written it should take the opportunity to teach parents
down. Organizations should therefore consider specific information about the drug (for exam-
implementing practices to reduce unnecessary ple, name of the medication, what it is for, how
interruptions and distractions during the medica- it works, what the exact dose is for the child,
tion administration process.32,33 and what possible adverse effects should be
105
TABLE 5-3. High-Alert Pediatric Drugs Associated with Medication Errors
Drug Class Hospitals Emergency Departments For Sedation

Adrenals/corticosteroids X
Analgesics—acetaminophen X
Anticoagulants X
Anti-infectives/antibiotics X X
Antihistamines X X X
Antineoplastics X X
Asthma medications X
Bronchodialators X X
Cardiac drugs X X
Electrolytes, minerals, and X
vitamins
Insulin X
Opiates (for example, X
morphine)
Sedatives (for example, opi- X
oids, benzodiazepines, chloral
hydrate, barbiturates)
Source: Hospitals: Kaushal R., et al.: Medication errors and adverse drug events in pediatric inpatients. JAMA
285:2114–2120, Apr. 25, 2001; Lesar T.S.: Errors in the use of medication dosage equations. Arch Pediatr Adolesc
Med 152:340–344, Apr. 1998; Hicks R.W., Becker S.C., Cousins D.D.: Harmful medication errors in children: A
5-year analysis of data from the USP’s MEDMARX program. J Pediatr Nurs 21:290–298, Aug. 2006; Holdsworth
M.T., et al.: Incidence and impact of adverse drug events in pediatric inpatients. Arch Pediatr Adolesc Med
157:60–65, Jan. 2003; Emergency Departments: Kozer E., et al.: Variables associated with medication errors in
pediatric emergency medicine. Pediatrics 110:737–742, Oct. 2002; For Sedation: Cote C.J.: Strategies for prevent-
ing sedation accidents. Pediatr Ann 34:625–633, Aug. 2005.
monitored for). Parents should also be taught physiological status; however, these adjust-
how to determine the correct dose and how to ments are vulnerable to miscalculations. To
properly administer the medication. avert potential pediatric medication errors,
nurses need to be well trained, double-check
Conclusion calculated doses, have the right technologies
to enhance clinical practice, and effectively
Pediatric medication administration errors communicate with the health care team, chil-
can be significantly reduced by using the best dren, and their families.
available information about each medication
and by ensuring that each dose is given in References
the right amount. Because adult medications 1. Phillips J., et al.: Retrospective analysis of mortali-
are used to treat children, each dose must be ties associated with medication errors. Am J Health
adjusted to account for the child’s weight and Syst Pharm 58:1835–1841, Oct. 1, 2001.
106
2. The Joint Commission: Preventing pediatric medi- 14. Beal A.C., et al.: Quality measures for children’s
cation errors. Sentinel Event Alert 39, Apr. 11, 2008. health care. Pediatrics 113(pt. 2):199–209, Jan.
http://www.jointcommission.org/assets/1/18/ 2004.
SEA_39.PDF (accessed May 12, 2011). 15. Yeung Y.W., Tuleu C.L.C., Wong I.C.K.:
3. Ferranti J., et al.: Reevaluating the safety profile National study of extemporaneous prepara-
of pediatrics: A comparison of computerized tions in English paediatric hospital pharmacies.
adverse drug event surveillance and voluntary Paediatric and Perinatal Drug Therapy 6:75–80,
reporting in the pediatric environment. Pediat- Sep. 15, 2004.
rics 121:e1201–e1207, May 2008. 16. Skaer T.L.: Dosing considerations in the pedi-
4. Horen B., Montastruc J.L., Lapeyre-Mestre M.: atric patient. Clin Ther 13:526–544, Sep.–Oct.
Adverse drug reactions and off-label drug use 1991.
in paediatric outpatients. Br J Clin Pharmacol 17. Stucky E.R., American Academy of Pediatrics
54:665–670, Dec. 2002. Committee on Drugs, American Academy of Pedi-
5. Aspden P., et al. (eds.): Patient Safety: Achiev- atrics Committee on Hospital Care: Prevention of
ing a New Standard for Care. Washington, DC: medication errors in the pediatric inpatient setting.
National Academies Press, 2004. Pediatrics 112:431–436, Aug. 2003.
6. Landrigan C.P.: The safety of inpatient pedi- 18. Sammons H., Conroy S.: How do we ensure
atrics: Preventing medical errors and injuries safe prescribing for children? Arch Dis Child
among hospitalized children. Pediatr Clin North 93:98–99, Feb. 2008.
Am 52:979–993, vii, Aug. 2005. 19. Wong I.C., Wong L.Y., Cranswick N.E.: Mini-
7. Slonim A.D., et al.: Hospital-reported medical mising medication errors in children. Arch Dis
errors in children. Pediatrics 111:617–621, Mar. Child 94:161–164, Feb. 2009.
2003. 20. Payne C.H., et al.: Pediatric medication errors
8. Miller M.R., Elixhauser A., Zhan C.: Patient in the postanesthesia care unit: Analysis of
safety events during pediatric hospitalizations. MEDMARX data. AORN J 85:731–740, Apr.
Pediatrics 111(pt. 1):1358–1366, Jun. 2003. 2007.
9. Kaushal R., et al.: Medication errors and adverse 21. Kozer E., et al.: Large errors in the dosing
drug events in pediatric inpatients. JAMA of medications for children. N Engl J Med
285:2114–2120, Apr. 25, 2001. 346:1175–1176, Apr. 11, 2002.
10. Harada M.J.C.S., Marin H.F., Carvalho W.B.: 22. Simpson J.H., et al.: Reducing medication
Ocorrências Adversas e conseqüências imedia- errors in the neonatal intensive care unit. Arch
tas para os pacientes em Unidade de Cuidados Dis Child Fetal Neonatal Ed 89:F480–F482,
Intensivos Pediátricos. Acta Paul Enferm Nov. 2004.
16:62–70, 2003. 23. Aronson J.K., et al.: A prescription for better
11. World Health Organization (WHO): Make prescribing. BMJ 333:459–460, Sep. 2, 2006.
Medicines Child Size. http://www.who.int/ 24. Rowe C., Koren T., Koren G.: Errors by paedi-
childmedicines/en/index.html (accessed May 1, atric residents in calculating drug doses. Arch
2011). Dis Child 79:56–58, Jul. 1998.
12. Fortescue E.B., et al.: Prioritizing strategies for 25. O’Shea E.: Factors contributing to medication
preventing medication errors and adverse drug errors: A literature review. J Clin Nurs 8:496–
events in pediatric inpatients. Pediatrics 111 504, Sep. 1999.
(pt. 1):722–729, Apr. 2003. 26. Ozkan S., et al.: Frequency of pediatric medica-
13. Crowley E., Williams R., Cousins D.: Medica- tion administration errors and contributing
tion errors in children: A descriptive summary factors. J Nurs Care Qual 26:136–143, Apr.–
of medication error reports submitted to the Jun. 2011.
United States Pharmacopeia. Curr Ther Res Clin 27. United States Pharmacopeia: Error-Avoidance
Exp 62:627–640, Sep. 2001. Recommendations for Medications Used in
107
Pediatric Populations. www.usp.org/hqi/ 30. Ghaleb M.A., et al.: Systematic review of

patientSafety/resources/pedRecom- medication errors in pediatric patients. Ann
mnds2003-01-22.html (accessed May 15, Pharmacother 40:1766–1776, Oct. 2006.
2011). 31. Drach-Zahavy A., Pud D.: Learning mecha-
28. Levine S., Cohen M.R.: Preventing medication nisms to limit medication administration errors.
errors in pediatric and neonatal patients. In J Adv Nurs 66:794–805, Apr. 2010.
Cohen M.R. (ed.): Medication Errors. Washing- 32. Westbrook J.I., et al.: Association of interrup-
ton, DC: American Pharmacists Association, tions with an increased risk and severity of
2007, pp. 469–492. medication administration errors. Arch Intern
29. The Joint Commission: Pediatric medica- Med 170:683–690, Apr. 26, 2010.
tion errors: Using the National Patient Safety 33. Stratton K.M., et al.: Reporting of medica-
Goals to protect patients. The Joint Commission tion errors by pediatric nurses. J Pediatr Nurs
Perspectives on Patient Safety 8:1–5, Jun. 2008. 19:385–392, Dec. 2004.
108
FOCUS: Patient Education
FOCUS
Patient Education:
Educating Parents About Their Children’s Medications in
Ambulatory Care
In ambulatory care, anywhere from 5% to 35% of adults and elderly outpatients will experi-
ence an adverse druge event (ADE).1 When pediatric patients in ambulatory care are the pri-
mary population, 16% of patients were affected by preventable ADEs, and 69% of the ADEs
occurred at the administration stage due to lack of parent education regarding the medication.2
Parents should be educated on their children’s medications, including potential side effects,
and should know when to promptly report their children’s side effects to health care providers.2
To educate parents on how to administer medications to their children safely, nurses can direct
them to the following resources:
• The Joint Commission’s Speak Up™ brochure for parents, Prevent Errors in Your Child’s Care
(http://www.jointcommission.org/assets/1/6/speakup_peds.pdf )
• Kids Aren’t Just Small Adults: Medicines, Children, and the Care Every Child Deserves, a
brochure from the U.S. Food and Drug Administration and the Consumer Healthcare Prod-
ucts Association (http://www.consumermedsafety.org/tools/KidsNotJustSmallAdults.pdf )
References
1. Stock R., Scott J., Gurtel S.: Using an electronic prescribing system to ensure accurate medication lists in
a large multidisciplinary medical group. Jt Comm J Qual Patient Saf 35:271–277, May 2009.
2. Kaushal R., et al.: Adverse drug events in pediatric outpatients. Ambul Pediatr 7:383–389, Sep.–Oct.
2007.
109
FOCUS
CHAPTER SIX Medication SAFETY:
Considerations for Geriatrics
AUTHOR: Trish O’Keefe, R.N., M.S.N., Morristown Memorial Hospital, Morristown, New Jersey
Ruth is a 91-year-old female who lives alone in her develop strategies to better identify a person’s
home. She is brought to the emergency department type of medications, ensure that this informa-
(ED) by an ambulance after falling in her laundry tion is coordinated during the transitions of
room. She is hard of hearing and appears alert and care, and communicate risks regarding the
oriented, although anxious and slightly forgetful. medications. These efforts are essential for the
No one has accompanied her to the hospital. Ruth patient’s safety and for the development and
requests the hospital staff to call her daughter, who implementation of the plan of care. Detailed
lives an hour away from the hospital. The daugh- and accurate information such as the history
ter, tells the nurse she is on her way. of the patient’s present medications and the
types, dosages, routes, schedules, and dura-
During the physical assessment, Ruth appears tion of medication use need to be available to
to have internal rotation of her left hip and leg. all caregivers.
She also has severe pain on slight movement of the
affected lower extremity and has apparent bruising The Impact of Our Aging
ө
on her arms. As the medical team reviews Ruth’s
Population on Health Care
past medical records, they read that she has a his-
tory of congestive heart failure, hypertension, tran- Statistics show that the segment of older
sient ischemic attacks, and a previous fractured adults (age 65 years or older) in America
right hip. has tripled in the past 100 years and that life
expectancy has grown to 77.2 years.1 By the
As part of the nursing assessment, the nurse ques- year 2030, experts forecast that the number of
tions the patient regarding medications she is tak- older adults will be approximately 70 million in
ing at home. The patient replies that she is taking the United States alone. These 70 million will
medications for her high blood pressure as well as a be 20% of the U.S. population, or one in every
clot-preventing drug. She does not know the names five U.S. citizens.
or dosages. The patient states to the nurse, “One of
the pills I take is blue, and the other is white.” The The increase in aging adults will raise the
patient cannot recall when she last self-administered demand for health care because older individu-
her medications. The nurse wonders, “Could these als are prone to a variety of chronic age-related
medications have caused her to fall? Might one of conditions. The Centers for Disease Control
her medications have caused the bruising on her and Prevention reports that approximately 80%
arms?” of aging adults live with one or more chronic
conditions.2 As a consequence, the use of
This scenario is a frequent occurrence in EDs medications by the elderly, both prescription
everywhere. As the elderly population con- and over-the-counter (OTC) drugs, is on the
tinues to increase both in the United States rise. Research shows that prescriptions have
and internationally, there is an urgent need to increased from 25% to 40% for U.S. elders.3,4
111
The elderly have become the biggest con- health care providers. Two well-known tools
sumers of medications.4 And, as consumption are the Beers Criteria and the Inappropriate
increases, so does the potential for drug- Prescribing in the Elderly Tool (IPET).
related problems. These problems include
inappropriate use, adverse drug events The Beers Criteria
(ADEs), drug–drug interactions, polyphar- The Beers Criteria (or Beers List) is a list of
macy, noncompliance, potentially inappropri- different categories of either single or multiple
ate medications (PIMs), and underutilization medications that are to be avoided by persons
of medications. It is projected that 35% of the age 65 years or older, as well as medications
elderly population will experience ADEs, 50% whose use is to be avoided by older patients
Defined: Beers Criteria of which could be prevented.5 Research sug- with certain medical conditions. The Beers Cri-
The Beers Criteria (or Beers List) gests that 62% of hospital admissions related teria classifies medications as posing “high” or
is a list of specific medications to ADEs were preventable and that 25% of “low” risk.3 Fick et al. updated the Beers List to
within medication classes that these ADEs were life-threatening.6 include 48 medications that should be avoided
are to be avoided by persons
in the elderly population and 20 medications
age 65 years or older, as well
as medications to be avoided Assessing Prescriptions for the that should not be used with specific medical
conditions or diagnoses. Two examples on
by those in that group who have Geriatric Population
particular medical conditions.3 that list of high-alert medications for the elderly
Raebel’s work focused on the filling of pre- with medical conditions are (1) patients with
scriptions for the elderly and found that primary COPD with beta blockers or those on seda-
care physicians wrote only half of all medical tive hypnotics and (2) patients with gastric or
prescriptions filled for their elderly patients.7 duodenal ulcers with NSAIDs (nonsteroidal
These patients received prescriptions from at anti-inflammatory drugs).9 Researchers have
least three other physicians, on average, and noted increased risk of ED visits and hospital-
had those prescriptions filled at several differ- izations in patients receiving medications that
ent pharmacies. Strategies such as merging meet the Beers Criteria.3
health care and pharmacy electronic systems
with online databases, development of geriat- The Beers Criteria, CMS, and long term
ric medical care and multidisciplinary teams, care. In 1999 the Beers Criteria3,4 was added
interventions from pharmacists, and physician to long term care guidelines by the Centers
involvement may decrease inappropriate pre- for Medicare & Medicaid Services (CMS). If
scribing in the elderly, but these strategies can patients in a long term care facility receive
be costly.8 medications on the list, the facility can be cited
by state licensing agencies.
Prescription Screening Tools
Due to a growing awareness of medication- Inappropriate Prescribing in the Elderly
related safety problems for the elderly, includ- Tool
ing dealing with multiple prescribers, methods The IPET, referred to by some as the “Cana-
have been developed to help caregivers such dian Criteria,” consists of a list of 14 common
as nurses identify potential errors in drug ther- prescribing errors identified from a com-
apy and prescribing patterns. These assess- prehensive list of inappropriate prescription
ment tools provide important assistance examples developed by an expert panel.9
toward decreasing adverse drug reaction The panel reviewed prescription practices
(ADR) and ADE rates. Several assessment and initially grouped the medications into
tools consisting of lists of medications that can four categories: cardiovascular, psychotro-
potentially cause adverse medication events pic, analgesic, and miscellaneous agents.9
in the elderly are available to nurses and other The expert panel then narrowed the list to
112
CHAPTER SIX: Medication Safety: Considerations for Geriatrics
14 medication errors that involved problem- knowledgeable about safe medication man-
atic medications in two categories: drug–drug agement principles in treatment of the elderly.
and drug–disease interactions similar to those Among the challenges that must be faced in
identified in the Beers Criteria. Two examples this patient population are age-related differ-
of drug–disease interactions from the IPET are ences in response to prescribed drugs. For
(1) NSAIDS and hyptertension and (2) tricyclic example, older adults have a reduced ability
antidepressants and arrhythmias. One of the to metabolize and excrete medications. These
differences between the IPET and the Beers and other factors should prompt consideration
Defined: Pharmacokinetics
Criteria is that the IPET is shorter. However, as of the pharmacokinetic and pharmacodynamic
and Pharmcodynamics
is the case with the Beers Criteria, the primary changes a drug might induce in an elderly Pharmacokinetics is the absorp-
limitation of the IPET is that it targets groups or patient. tion, distribution, metabolism,
classes of medications without addressing the and excretion of medications.
appropriateness of a complex individual medi- Pharmacokinetics and pharmcodynamics can Pharmacodynamics is the physi-
cation plan for an elderly person, particularly influence the development of ADRs in the geri- ological and therapeutic effect
in relation to any unusual circumstances when atric population. Research studies have been of a drug at the site of or on the
targeted organ.10
the benefit of prescribing the medication(s) limited, but evidence has shown marked dif-
outweighs the risk to the patient.9 ferences in the geriatric patient responses to
certain medications. Responses may include
Medication Appropriateness Index increased myocardial sensitivity to anesthetic
Another prescription assessment tool is the agents and higher central nervous system
Medication Appropriateness Index (MAI), receptor sensitivity to narcotics, alcohol, and
which screens the overall quality of prescrip- bromides.11 These key age-related changes
tions in 10 separate but related categories. in older persons, as well as changes in drug
The difficulty in using this tool is the lack of absorption, distribution, metabolism, and elim-
specific guidance on the impact of particular ination (or clearance of medications), must be
medicines and the tool’s limited application to considered when prescribing medications to
defining inappropriate prescribing of medica- the older adult.
tions.9 Because not all types of medications
are prescribed in similar ways around the High-Alert Medications in
world, some countries—such as England and
Geriatric Patient Regimens
Australia—are conducting studies to further
define and tailor assessment tools to address A number of high-alert medications are fre-
problematic patterns of prescribing for the quently found in the often complex regimens
elderly in their health care systems.8 of elderly patients. For this reason, nurses
need to be knowledgeable regarding common
It is important to note that although the use of high-alert medication in older adults. Assess-
prescription assessment tools has been found ment for potential ADEs, drug–drug interac-
to decrease the risk of medication errors for the tions, and drug–food interactions is essential
elderly population, these tools cannot replace in maintaining a therapeutic regimen.
the critical responsibility of the prescribing cli-
nician to weigh the prescribed medication’s Anticoagulants
therapeutic benefit against the risk of ADEs. One class of high-alert medications commonly
used by older adults is anticoagulants. The
Pharmacokinetic and Pharmacodynamic need for anticoagulation therapy is steadily
Changes increasing because of the prevalence of atrial
As medication use in the aging popula- fibrillation and venous thrombosis in the aging
tion continues to increase, nurses must be population.12 Anticoagulation therapy involves
113
the use of several commonly prescribed medi- Antihypertensive Agents and

cations, which include but are not limited to Cardiovascular Medications
warfarin, heparin, and low molecular weight Other important high-alert medications com-
heparin. Warfarin has a narrow therapeutic monly used in the geriatric population include
index, and metabolism and excretion can vary antihypertensive agents and cardiovascular
widely. Thus, maintaining and achieving an medications. Antihypertensive agents have
appropriate, safe level can be difficult, particu- the ability to cause orthostatic hypotension,
larly in the aged population, who are at a high which may result in a higher risk of falls in
risk of falls and potential traumatic events.12 compromised older adults.14 In addition, com-
monly prescribed beta-blocking antihyperten-
Patient education for warfarin. Patient—and sive agents have been related to depression
family—education regarding warfarin needs to in this population.15 Many older adults have
address the following13: experienced compromise in renal functioning
• Potential drug–food interactions, includ- due to age. Because some medications, such
ing those with vitamin K–rich foods such as digoxin, are cleared by the kidneys, moni-
as green leafy vegetables, cauliflower, toring of renal function is particularly important
and cranberry juice (warfarin is a vitamin K to identify the potential for digoxin toxicity.16
antagonist)
• Review of herbal therapies, which influence Physiological Impacts
a patient’s International Normalized Ratio
(INR) in terms of bleeding time In addition, age-related physiological changes
• Preexisting medical factors affect medication management in the elderly.
• Assessment of bleeding potential These physical reactions may be targeted
• The signs and symptoms of intracerebral in the gastrointestinal, genitourinary, and
hemorrhage (ICH): nausea and vomiting, immune systems. Nurses must also be aware
The Joint Commission’s
National Patient Safety Goal new onset of headache of skin discoloration and lack of elasticity that
NPSG.03.05.01 states, “Reduce may occur in the elderly and potentially cause
the likelihood of patient harm Best practices for anticoagulation therapy. difficulty in the patient’s thermoregulation.
associated with the use of To respond to and monitor this growing high- These changes may increase the risk of intra-
anticoagulant therapy.” This alert, often long-term therapy in the geriatric venous (IV) infiltrations and affect absorption
requirement applies only to population, multidisciplinary anticoagulation of suppositories in the lower bowel.
organizations that provide antico-
clinics are being developed across the United
agulant therapy and/or long-term
anticoagulation prophylaxis (for
States. However, many patients will continue Assessment of the patient’s capacity to swal-
example, atrial fibrillation) where to be managed in primary care settings with- low oral medications effectively is also essen-
the clinical expectation is that the out the type of follow-up that such clinics may tial. Although the most common and easiest
patient’s laboratory values for provide. For that reason, nurses should be administration of medication is the oral route,
coagulation will remain outside trained in best practices for anticoagulation certain challenges can affect this administra-
normal values. therapy. Key best practices include consistent tion process for the elderly: Dry oral mucous
INR monitoring for warfarin, patient education membranes, limited swallowing mobility, and
regarding drug–drug and drug–food interac- improper fit of dentures can affect the safe
tions, and medication reconciliation at all tran- digestion of medications.11 Nursing interven-
sitions of care. A heightened awareness of tions such as good oral hygiene, adequate
signs and symptoms of adverse effects (par- fluid intake, and proper positioning should be
ticularly bleeding) and monitoring must also part of the oral medication administration.
be included to ensure that safety precautions
regarding falls are in place.7
114
Sensory Impacts options, and attending to the basic needs of

how an older adult can manage to open a
The physical and cognitive ability to accurately pain medication vial or pill box all need to be
read medication labels, use aids for tracking addressed throughout the continuum of care.18
self-medication (such as pill counters), and It is crucial that nurses, as key members of the
self-administer medications, particularly those interdisciplinary team, understand myths asso-
with more complex administration techniques ciated with pain management. These myths
(such as eyedrops, inhalers, and injections), include the addictive potential of pain medica-
can be problematic for the elderly. In addition, tions and the belief that pain is a normal result Joint Commission Provision of
elderly patients may find it challenging to deal of aging. Understanding these myths allows Care, Treatment, and Services
with storage requirements for multiple drugs, the nurse to provide optimal physical and sup- (PC) Standard PC.01.02.07
obtain refills of prescriptions, and ensure that portive care and the necessary education to states, “The organization
their drugs have not passed their expiry dates. patients and families about managing pain.17 assesses and manages the
The patient’s capacity to handle these tasks resident’s pain.”
needs to be assessed by all health care pro- The Frail Elderly
fessionals, and strategies to ensure safe med-
ication handling should be implemented. Frailty, disability, and impairment can also be
common among the aged—and can have pro-
Chronic Pain found effects on medication management. A
One of the chief chronic sensory impacts on person is considered frail if he or she has at
the aged population is pain. Pain is associated least three of the following symptoms: weight
with a number of conditions—both chronic loss (of 10 pounds or more in a year), slow
(for example, osteoarthritis) and acute (for walking speed, low grip strength, fatigue, poor
example, surgery). Therefore, pain can be a endurance, or low levels of activity.19
frequent, yet subjective, experience to which
older adults can be particularly vulnerable. Many elders have survived conditions that
Many older adults deal with chronic pain as earlier in history were fatal but that now are
part of their daily activity. Despite its preva- treatable. However, the elderly may have to
lence, however, evidence suggests that pain live with a chronic disability, such as limited
is often poorly assessed and poorly man- mobility, chronic pain, or impaired communi-
aged, particularly in older adults.17 Challenges cation. These disabilities create special safety
in cognitive impairment such as dementia hazards, particularly with respect to medica-
(Alzheimer’s) present a particular challenge tion management. Many frail elderly patients
to chronic pain management because older have multiple comorbidities, such as hyper-
adults with such a condition may be unable to tension, myocardial infarction, depression,
communicate their pain effectively. and diabetes mellitus. These chronic illnesses
often require management with medications,
Pain and medications. Pain also affects the which creates problems with polypharmacy.8
elderly in their activities of daily living and
functioning. It can be associated with lack of The goals of medication management in the
sleep, depression, increased dependence, frail elderly differ from those for younger and
and decreased socialization. Strategies such middle-aged adults. Assessing functional and
as systematically assessing the level of pain cognitive capacity is essential to ensure medi-
and its impact on functioning, developing a cation safety and adherence to medication
well-coordinated treatment plan that includes regimens in this population, as is consistent
pain-relieving medications, employing inter- medical and nursing oversight.
ventional and complementary technique
115
Fundamental Nursing Strategies of life changes may trigger depression and

in Geriatrics anxiety episodes. Research has suggested
that depression in the elderly ranges from
Detailed medication history, assessment, and 15%–25% of community-based older adults to
medication management are essential for the as high as 25% of elders residing in long term
safety of the geriatric population in acute care care facilities.21 Symptoms such as increased
and all levels of care transitions. At the time headaches, irregular sleep patterns, and
of hospital admission, approximately 67% of changes in digestion and bowel habits need to
elderly patients provide incorrect details about be evaluated medically, but with an awareness
the medications they take, and 83% do so that these are also common manifestations in
when the medication history includes nonpre- depression. Studies done in Britain revealed
scription drugs.20 To improve these statistics, that conditions such as depression can mani-
several fundamental nursing and other health fest as confusion with memory problems,22 as
care provider strategies are recommended well as reduced motivation and isolation, all of
in the geriatric clinical literature. Examples of which increase the risk in managing self-care.
these strategies are explained in the following
sections. A patient’s history should therefore include
assessment of recent personal and social
changes and any increased stress in the
elder’s living environment. Nurses need to
At the time of allow ample time for communication with the
hospital admission, patient—speaking to the patient if he or she
approximately 67% of is lucid—and attempt to decrease distractions
elderly patients provide and prevent overstimulation during assess-
incorrect details about ment so the patient can focus clearly on the
the medications they questions.
take, and 83% do so
when the medication Provide and Update Comprehensive
history includes Home Medication Lists
nonprescription drugs.20 Assessment of medication use includes a
review of the types, dosages, and frequency
of current medications as well as the length of
time the older adult has been taking the medi-
Incorporate Psychosocial Conditions into cation.23 Health care settings can be very con-
Medical Histories fusing and threatening to the elderly who may
Physical and psychosocial evaluation are be unable to recall information regarding their
both part of a comprehensive medical history. medications. Some hospitals have offered to
In addition to physical ailments, older adults assist in the medication process by providing
can exhibit psychological problems such as wallet-sized medication cards to their patients
depression and anxiety. Some elders may on discharge. The medication cards allow
exhibit these symptoms earlier in their lives, discharged patients to have their updated
but such symptoms can be exacerbated medication list readily available for the next
when an individual is faced with life-changing transition in their care or for any future health
events such as retirement, loss of a significant care needs. (See pages 65–66 in Chapter 3
other (spouse, family member, friend), limited for an example of these cards and their use in
physical and social independence, and cop- a medication reconciliation program.)
ing with the reality of mortality. These types
116
Use the “Brown Bag” Method to Support medications, including OTCs, herbal or other
Medication Reconciliation folk remedies, and recreational drugs, alco-
Organizing regular reviews of all medications hol, and caffeine. It is crucial to have complete
with a provider/hospital/health care setting information about all forms of medications to
promotes medication education and recon- verify a patient’s accurate medication regimen
ciliation. In the “brown bag” method, patients at all transitions of care. In the standards, The
are invited to bring all existing prescriptions, Joint Commission stresses the importance of
including OTC and herbal medications/prod- a focus on risk points and on an accurate and
ucts, to their health care provider for review. complete medication reconciliation process
This method allows the practitioner to examine across the continuum of care. Relevant Requirements
the medication types and expirations, look for Examining whether medications
may be a cause of falls is a strat-
therapeutic duplications or discontinued medi- Consider Medications as Potential Causes
egy that is supported in the Joint
cations, and identify generic versus brand- of Falls Commission’s National Patient
name drugs.24 This evaluation should also Many environmental settings can pose poten- Safety Goal 9 for long term care:
include assessment of any drugs being shared tial extrinsic risks for falls in the elderly. Nurses “Reduce the risk of patient harm
with spouses or friends and pets as well as and all health care workers must consider the resulting from falls.” It is also
identification of a lack of a medication admin- intrinsic risks and impact of certain medica- supported by Joint Commission
istration routine.8 Some community health tions on an older adult in a foreign environ- International’s International
centers have offered Brown Bag Screening ment. Certain categories of medications such Patient Safety Goal 6: “The or-
ganization develops an approach
Days. Local pharmacists and nurses in the as sedatives/hypnotics, antidepressants, and
to reduce the risk of patient harm
community are available to review and evalu- benzodiazepines are described as “culprit
resulting from falls.”
ate patient medications for redundancies, medications” that may increase an elderly per-
dispose of outdated medications, and offer son’s risk for falls.25
education, particularly on high-alert medica-
tions. In addition, these types of screenings Provide Clear Patient Education About
allow caregivers to assess important factors in Medications Relevant Requirements
medication management, inlcuding a patient’s Regardless of the strategy used, caregivers— Joint Commission Medication
ability to use medication delivery devices such including nurses—need to provide the elderly Management (MM) Standard
as inhalers. patient with clear explanations of what the MM.05.01.09, applicable to
prescribed medication is for, when and how all U.S.–based programs that
Examine All Medication Containers for it should be taken, and possible side effects prepare/dispense and administer
medications, states, “Medica-
Clear Labeling from taking the medication. When appropriate,
tions are labeled.” The rationale
Health care providers should have a process the family or caregivers should be included in
for this standard states, “A
to evaluate medication containers to ensure teaching efforts to encourage adherence and label on every medication and
that the containers and other medical solu- to reinforce safe behaviors. medication container has long
tions are labeled to prevent inadvertent admin- been a standard of practice by
istration of the wrong drug. Also important for Conclusion the pharmacy profession and is
the elderly is an assessment of the labeling in required by law and regulation.
conjunction with an evaluation of the patient’s As our elderly population continues to A standardized method to label
medications and containers
potential visual deficits to ensure that he or increase, nurses as patient advocates need to
promotes medication safety.”
she can read the medication label correctly. prioritize medication management strategies
to support this important group in our society.
Ask Detailed Questions to Compile a Older adults are faced with many challenges
Complete Medication Record as they age and use multiple medications to
During the initial patient assessment, includ- sustain their health and prevent complications.
ing the medication reconciliation process, These challenges include visual and hearing
detailed questions must be asked regarding all impairment, arthritic and weak joints, cognitive
117
impairment, and lack of knowledge regarding One such program is Nurses Improving Care
medications, as well as noncompliance. In for Health system Elders (NICHE), developed
response to this special population’s multifac- by the Hartford Institute for Geriatric Nursing at
eted issues, health care facilities have begun New York University College for Nursing. This
implementing strategies to support geriatric program provides principles and tools to stimu-
needs across the continuum of care. late change in the culture of health care facilities
to promote safe medication management to the
These efforts include risk-reduction processes older patient population, as well as other initia-
targeted at compliance with the Joint Com- tives aimed at safer elder care. Presently there
mission’s Medication Management standards. are 300 hospitals throughout North America,
The standards feature the elements of plan- parts of Canada, and the Netherlands adopt-
ning, selection and procuring, storage, ordering the NICHE concepts. One of the key NICHE
ing, preparing and dispensing, administration, principles is that medications should be pre-
monitoring, and evaluation. Some examples of scribed for and administered to older adults in an
risk-reduction strategies are the pharmacist’s evidence-based manner. In the NICHE model,
role in profiling all medications, including pre- nurses play a pivotal role in implementing pre-
scription and OTC medications; patient and ventive strategies for the reduction of ADEs in
family education on the medications received, this vulnerable population.27 However, nurses in
including the intended effect and possible side all health care settings need to be cognizant of
effects; medication reconciliation at all transi- the challenges faced in providing safe medica-
tion-of-care points; and, particularly, identification management in the geriatric population.
tion of special precautions regarding high-alert
drugs, which have an increased risk of harm to References
patients, particularly the aged patient. 1. Smeltzer S.C., et al.: Brunner & Suddarth’s Text-
book of Medical-Surgical Nursing. Philadelphia:
Other strategies include reviewing potential Lippincott, Williams & Wilkins, 2008.
breakdowns in handoffs from each caregiver 2. Centers for Disease Control and Prevention,
along the continuum, implementing a comput- Merck Company Foundation: The State of Aging
erized provider order entry system (CPOE), and Health in America 2009. http://apps.nccd.
profiling all patient medications with indepen- cdc.gov/Aging/pdf/Saha_2007.pdf (accessed
dent verification for accuracy, and requiring Aug. 28, 2011).
that therapeutic indications be added to medi-
3. Fick D.M., et al.: Updating the Beers Criteria
cation orders to prevent errors due to look-
for potentially inappropriate medication use in
alike/sound-alike medications.
older adults: Results of a U.S. consensus panel
of experts. Arch Intern Med 163:2716–2724,
Participation of the elder patient and his or her
Dec. 8–22, 2003.
significant others is important to ensure individ-
4. Beers M.H., et al.: Explicit criteria for determin-
ualized and appropriate medication manage-
ing inappropriate medication use in nursing
ment. Strategies/approaches (identifying each
home residents. Arch Intern Med 151:1825–
medication by name before administering it to
the patient, asking the patient to state his or 1832, Sep. 1991.
her name, and using two identifiers) are impor- 5. Safran D.G., et al.: Prescription drug coverage
tant to ensure safe medication management.26 and seniors: Findings from a 2003 national
survey. Health Aff (Millwood) (suppl. Web
Programs with a patient-centered approach to exclusives):W5-152–W5-166, Jan.–Jun. 2005.
care and focused on providing better outcomes 6. McDonnell P.J., Jacobs M.R.: Hospital admis-
are particularly important to geriatric patients. sions resulting from preventable adverse drug
118
reactions. Ann Pharmacother 36:1331–1336, 19. Fried L.P., et al.: Frailty in older adults:
Sep. 2002. Evidence for a phenotype. J Gerontol A Biol Sci
7. Raebel M.A., et al.: Randomized trial to Med Sci 56:M146–M156, Mar. 2001.
improve prescribing safety in ambulatory elder 20. Tam V.C., et al.: Frequency, type and clini-
patients. J Am Geriatr Soc 55:977–985, Jul. cal importance of medication history errors
2007. at admission to hospital: A systematic review.
8. Kaur S., et al.: Interventions that can reduce CMAJ 173:510–515, Aug. 30, 2005.
inappropriate prescribing in the elderly: A 21. Cassidy E.L., Lauderdale S., Sheikh J.I.: Mixed
systematic review. Drugs Aging 26(12):1013– anxiety and depression in older adults: Clini-
1028, 2009. cal characteristics and management. J Geriatr
9. Barry P.J., et al.: Inappropriate prescribing in the Psychiatry Neurol 18:83–88, Jun. 2005.
elderly: A comparison of the Beers Criteria and 22. Royal College of Psychiatrists: Raising the
the Improving Prescribing in the Elderly Tool Standard: Specialist Services for Older People with
(IPET) in acutely ill eledrly hospitalized patients. Mental Illness. 2006. http://www.rcpsych.ac.uk/
J Clin Pharm Ther 31:617–626, Dec. 2006. PDF/RaisingtheStandardOAPwebsite.pdf
10. Mangoni A.A., Jackson S.H.: Age-related (accessed Apr. 22, 2011).
changes in pharmacokinetics and pharma- 23. Lau H.S., et al.: The completeness of medica-
codynamics: Basic principles and practical tion histories in hospital medical records of
applications. Br J Clin Pharmacol 57:6–14, Jan. patients admitted to general internal medicine
2004. wards. Br J Clin Pharmacol 49:597–603, Jun.
11. Eliopoulos C.: Gerontological Nursing, 6th ed. 2000.
Philadelphia: Lippincott, Williams & Wilkins, 24. Nathan A., et al.: “Brown Bag” medication
2005. reviews as a means of optimizing patients’ use of
12. Gouin-Thibault I., et al.: Improving anticoagu- medication and of identifying potential clinical
lation control in hospitalized elderly patients problems. Fam Pract 16:278–282, Jun. 1999.
on warfarin. J Am Geriatr Soc 58:242–247, Feb. 25. Oliver D., et al.: Risk factors and risk assess-
2010. ment tools for falls in hospital in-patients: A
13. Cranwell-Bruce L.A.: Anticoagulation therapy: systemic review. Age Ageing 33:122–130, Mar.
Reinforcing patient education. Medsurg Nurs 2004.
16:55–58, Feb. 2007. 26. Santell J.P., et al.: Medication errors: Experi-
14. Ooi W.L., Hossain M., Lipsitz L.A.: The asso- ence of the United States Pharmacopeia (USP)
ciation between orthostatic hypotension and MEDMARX reporting system. J Clin Pharmacol
recurrent falls in nursing home residents. Am J 43:760–767, Jul. 2003.
Med 108:106–111, Feb. 2000. 27. Capezuti E., et al.: Evidence-Based Geriatric
15. Nolan P.E. Jr., Marcus F.I.: Cardiovascular Nursing Protocols for Best Practice, 3rd ed. New
drug use in the elderly. Am J Geriatr Cardiol York: Springer, 2007.
9:127–129, May 2000.
16. Flaherty J.H., et al.: Polypharmacy and hospital-
ization among older home care patients.
J Gerontol A Biol Sci Med Sci 55:554–559, Oct.
2000.
17. Horgas A., Miller L.: Pain assessment in people
with dementia Am J Nurs 108:62–70, Jul. 2008.
18. D’Arcy Y.: How to Manage Pain in the Elderly.
Indianapolis: Sigma Theta Tau, 2010.
119
FOCUS
Staff Education:
Medication Technicians in Long Term Care
An emerging issue in long term care is the use of medication technicians (or trained certified
nursing assistants) to administer low-risk medications under nursing supervision.1,2 Due to
the nursing shortage and fiscal constraints, long term care organizations in more than 30 U.S.
states and several industrialized countries have adopted policies allowing medication techni-
cians with minimal formal training to administer routine medications to stable patients.2
Government Regulations
The training and competency assessment required of medication technicians before they are
allowed to administer medications in long term care organizations varies from state to state
and country to country. Currently, 15 U.S. states that allow certified nursing assistants to
administer medications in long term care organizations require a formal education program,
and 14 of those states specify a minimum number of course hours, ranging from 20 to 140.2
Furthermore, 6 of the U.S. states that permit medication technicians require that the techni-
cians pass an examination with a specific minimum score.2
Risks for Medication Errors

A few peer-reviewed studies researching the safety of using medication technicians state that
there are similar risks for medication errors when licensed nurses (R.N.s or L.P.N.s) administer
medications as when medication technicians administer low-risk medications in long term care
organizations.2 However, one multistate study found that nursing homes with fewer licensed
nurses and that used medication technicians more frequently had a greater risk of having at
least a 5% medication error rate.2
Recommendations for Using Medication Technicians in Long Term Care to

Administer Medications
If long term care organizations are legally allowed to use use medication technicians to admin-
ster medications, they should address the following2:
• Delegation: Licensed nurses should understand how to delegate to medication technicians
and know exactly what medications the technician can administer. Basic delegation rules
include the following:
◦ Do not delegate the first dose of a medication or any medications for which the dose has
just been changed.
◦ Do delgate regularly scheduled medications to residents if they are given orally, topically,
nasally, rectally, or in the eye or ear.
◦ Only delegate as-needed medications with indications for bowel care or over-the-counter
analgesic agents.
• Responsibility: Licensed nurses are still responsible for monitoring patients for adverse effects
after medications are given, including those medications given by medication technicians.
120
FOCUS: Staff Education
FOCUS
Staff Education:
Medication Technicians in Long Term Care (continued)
• Clinical Competencies: Medication technicians must be taught basic pharmacology and

medication administration principles and be evaluated for their knowledge thereafter.
The instructors in this training should be R.N.s or L.P.N.s with experience in teaching
and administering medications to long term care residents. (Seven U.S. states require that
instructors be R.N.s.) Clinical competencies may include the following2:
◦ Know the “five rights” of medication administration when administering medications to
stable residents after being delegated and supervised by a licensed nurse.
◦ Understand when to acceept a delgation of a medication (for example, an oral medica-
tion to a stable patient) and when to decline a delegation (for example, for a sublingual
medication).
◦ Document the medication administration accurately.
◦ Notify the delegating nurse of any changes in the resident’s condition.
◦ Maintain the resident’s rights during medication administration (including honoring the
resident’s right to refuse the medication).
In one study, researchers adopted a 100-hour curriculum and found that 72% of the trainees
passed the competency exams to become medication technicians. Trainees who did not pass
showed problems with basic math skills and reading abilities.2
References
1. Scott-Cawiezell J., et al.: Nursing home error and level of staff credentials. Clin Nurs Res 16:72–78, Feb.
2007.
2. Randolph P.K., Scott-Cawiezell J.: Developing a statewide medication technician pilot program in nurs-
ing homes. J Gerontol Nurs 36:36–44, Sep. 2010.
121
FOCUS
Antipsychotic Medications in Long Term Care
Typical and atypical antipsychotics have commonly been used off-label to treat dementia-
related psychosis (or symptoms of aggression, agitation, hallucination, and wandering among
individuals with dementia) among the elderly.1 According to the Centers for Medicare &
Medicaid Services (CMS), nearly 30% of nursing home residents are receiving antipsychotic
medications, and 21% of those patients receiving antipsychotics do not have a recorded psy-
chosis diagnosis.2 However, recent studies have shown that individuals with dementia-related
psychosis who are taking antipsychotics have an increased risk for stroke and mortality.1 As a
result, the U.S. Food and Drug Administration (FDA) issued a black box warning for atypical
antipsychotics (in 2005) and typical antipsychotics (in 2008) used to treat dementia-related
psychosis. Furthermore, the CMS created F-Tag 329 to ensure that antipsychotic medications
are used appropriately for residents with behavioral issues and that the medications are titrated
down to the lowest possible dose if they cannot be discontinued.3 In addition, the American
Psychological Association continues to endorse the use of antipsychotics for treating dementia-
related psychosis when other nonpharmacologic interventions have failed.1
In a survey of geriatric practitioners regarding the FDA warning on antipsychotics for treating
dementia-related psychosis, respondents said that guidelines need to be developed to address
the FDA warning and that better nonpharmacologic alternatives need to be found for treating
patients with dementia-related psychosis.1
Nonpharmacological Approaches to Treating Behavioral Issues Among

Long Term Care Residents
Some nonpharmacological approaches to treating aggression and other behavioral issues among
long term care residents are music therapy, massage therapy, and pet therapy.1 One study of
residents with dementia or Alzheimer’s disease in 670 nursing homes in New York found that
after the antipsychotic medications were discontinued for this population, residents were more
alert and communicative.4
Address the underlying issue. In addition, researchers found that the strongest contributor
for improving behavioral problems among residents is to address the underlying issue for the
aggression (such as pain or hunger) and provide positive intermittent reinforcement, both of
which take effort, patience, and communication among staff, residents, and families.4
Personalize the approach. Other long term care organizations have found success by per-
sonalizing the ways in which they address residents’ agitation. For example, a staff member
found that she could calm an aggressive patient by chatting with her and giving her ice
cream.2
122
FOCUS
Antipsychotic Medications in Long Term Care (continued)
Increase staff and staff education. To use these nonpharmacological approaches to aggres-
sive behavior, organizations may need to increase staffing levels2 and will need to provide effec-
tive training for staff in caring for patients who become aggressive.3 When patients are cared
for in the home, nurses need to coach family members on finding effective ways to care for the
patient nonpharmacologically. Unfortunately, given the current health care payment models,
costs of prescription medications are more readily reimbursed through health insurance plans
than are expenses involved in securing extra staff to provide individualized care for aggressive
residents.2
References
1. Saad M., Cassagnol M., Ahmed E.: The impact of FDA’s warning on the use of antipsychotics in clinical
practice: A survey. Consult Pharm 25:739–744, Nov. 2010.
2. Lagnado L: Prescription abuse seen in U.S. nursing homes: Powerful antipsychotics used to subdue
elderly; huge Medicaid expense. Wall Street Journal, Dec. 4, 2007. http://online.wsj.com/article/
SB119672919018312521.html (accessed Apr. 10, 2011).
3. Stefanacci R.G.: Evidence-based treatment of behavioral problems in patients with dementia. Ann
Longterm Care 16, Apr. 2008. http://www.annalsoflongtermcare.com/article/8616 (accessed Feb. 28,
2011).
4. Kaldy J.: Antipsychotic reduction efforts pay off: Study presented at annual symposium showed fewer
falls once drugs were stopped. Caring for the Ages, Jun. 1, 2009. http://www.caringfortheages.com/news/
more-top-news/single-view/antipsychotic-reduction-efforts-pay-off-study-presented-at-annual-
symposium-showed-fewer-falls-once-drugs-were-stopped/3b65ad313d397aac9eb2f9f00429c0a2.html
(accessed Apr. 10, 2011).
123
CHAPTER SEVEN Medication SAFETY:
Considerations for Obstetrics
AUTHORS: Mary C. Brucker, C.N.M., Ph.D., F.A.C.N.M., Louise Herrington School of Nursing, Dallas;
and Tekoa L. King, C.N.M., M.P.H., F.A.C.N.M., University of California, San Francisco, and Deputy
Editor, Journal of Midwifery and Women’s Health
Obstetrics (OB) is an area in which nurses and Gynecology published a clinical opinion
have wide latitude and authority regarding paper suggesting more authority and respon-
drug administration. Nurses caring for laboring sibility for the professional (that is, the nurse)
women are intimately involved in the choice at the woman’s bedside in managing use of
and timing of drugs offered. Perinatal nurses this drug.2
often work with standing orders that allow for
different choices among several medications. Reconstituting of Perinatal Drugs
Therefore, perinatal nurses must possess in- Medications are often stored on a perinatal
depth knowledge about the agents commonly unit, particularly in labor and delivery, because
used in this field. there often is no time to wait for agents to be
delivered from a pharmacy for women in active
Challenges for Nurses in the need. Therefore, drugs may be reconstituted
to obtain correct dosing at the bedside, poten-
Perinatal Arena
ө
tially incurring more risk of a dosing error.
Labor and delivery units are often considered
to be critical care areas. Appropriate staffing Off-Site Team Members
is integral to safety but may not always be In some situations, the physician or midwife
possible. Even when the number of nurses is off site, and communication about the prog-
implies adequate coverage, unanticipated sit- ress of a woman in labor is via phone or fax.
uations occur. For example, many women can More than 70% of OB sentinel event cases
be delivering simultaneously, and when this have been noted to relate to poor communica-
occurs, omission or mistiming of drug adminis- tion and teamwork.3
tration for other women is a potential problem.
Thus, a list of some of the challenges specific PRN (“As Needed”) Medications
to perinatal nursing is in order. Nurses de facto often initiate a prescription
by personally determining when to call a phy-
Nurses’ Familiarity with Obstetric Drugs sician or midwife for intrapartum pain relief
Perinatal nursing is considered a nursing spe- medication orders or when to administer PRN
cialty. Thus, nurses new to this discipline may (as needed) medications. The nurse therefore
be unfamiliar with obstetric-specific drugs such needs to know the rate of onset, mechanism
as oxytocin and magnesium sulfate. Oxytocin of action, dose, and timing for several differ-
is recognized by the Institute for Safe Medi- ent drugs that can be used to treat the same
cation Practices as a high-alert medication.1 It condition.
should be noted that after oxytocin was so cat-
egorized, the American Journal of Obstetrics
125
Suggested Methods to Improve direct nursing care as they deliver in a hos-

Perinatal Safety pital or birth center.5 Although births are com-
mon, each maternal/fetal dyad is unique. The
Many generic methods to promote drug safety obstetrical nurse simultaneously cares for two
can be found elsewhere in this book. Spe- individuals, each with a separate physiologic
cific suggestions for how perinatal nurses can system and different physiologic needs. Phar-
ensure medication safety include the following: maceutical therapies can be specific for the
• Simplify and standardize medication mother, the fetus, or both. Some agents are
processes. best avoided or administered only at specific
Sentinel Event
According to The Joint Com- • Use written guidelines or forms containing times during the reproductive cycle. For exam-
mission, a sentinel event is an key details—for instance, recommended ple, an antihistamine commonly may be used
unexpected occurrence involving doses of medications and medication prep- therapeutically during pregnancy, but avoided
death or serious physical or arations. These are effective methods for during lactation, because this drug can poten-
psychological injury, or the risk promoting evidence-based practice. Reli- tially affect the supply of breast milk.6 Tetra-
thereof. Serious injury spe- ance on memory is particularly dangerous in cycline is contraindicated during pregnancy
cifically includes loss of limb or
a setting characterized by time constraints, because it forms nonabsorbable complexes
function. The phrase “or the risk
stress, and nurse fatigue. Distractions are with the calcium in breast milk, yet tetracy-
thereof” includes any process
variation for which a recurrence common when women are giving birth. cline may be used without serious risk to the
would carry a significant chance • Emphasize commonly agreed-on terms breastfeeding neonate if other antibiotics are
of a serious adverse outcome. for communication among teams. For not available.
Such events are called sentinel example, when discussing the effects
because they signal the need of oxytocin on fetal heart rate patterns,
for immediate investigation and
misuse of terms for specific types of fetal
response.
heart rate decelerations can result in diag- Although births
nosis and management errors. Use team are common, each
simulations to promote optimal manage- maternal/fetal dyad is
ment of high-risk, low-frequency events. unique. The obstetrical
Dealing with these events often requires nurse simultaneously
or otherwise involves medications, such as cares for two
oxytocin-related uterine ruptures. During individuals, each with
the simulations, encourage shared learn- a separate physiologic
ing regardless of hierarchy of authority and system and different
encourage providers to consider reaching physiologic needs.
consensus with their colleagues regarding
drugs and dosage to be used.
• Employ technology to prevent medication
errors—for instance, with clear charting in Paucity of Relevant Information
an electronic health record (EHR).4 (See One of the major challenges in the care of the
Chapter 2.) pregnant or postpartum woman and her off-
spring is the paucity of relevant information
The Common, but Unique Field readily available to both the health care pro-
vider and the consumer. Much information that
of Obstetrics is accessible to the public comes from less-
In the United States, 82% of women age than-credible Web sites, often ones that are
15–44 have given birth at least once, and unnecessarily inflammatory, mandating that
there are approximately 4 million births annu- women avoid all medications, an unattainable
ally, with the overwhelming majority receiving goal. Health education about drugs during
126
CHAPTER SEVEN: Medication Safety: Considerations for Obstetrics
pregnancy, during labor, and postpartum is an abuse, and suicide, all of which adversely
integral part of the nurse’s role with this popu- affect both mother and fetus.10 Treatments for
lation. Although this information gap is trou- depression, such as lithium and selective sero-
bling, most women and children are healthy, tonin reuptake inhibitors (SSRIs), are associ-
and the drugs that are routinely employed fall ated with a small risk of congenital disorders
into a relatively short list. in the baby, yet they have a wide variety of
maternal side effects. In many cases the risks
The Prenatal Period of adverse effects associated with treating
depression are less than the risks of adverse
Medications are never to be used cava- effects associated with untreated depression.
lierly during pregnancy. Over the last several
decades, however, the incidence of drug use Pregnancy Categories for the Drug
in pregnancy, including the first trimester, Formulary
has doubled in the United States.7 In part, When nurses and other health care providers
the increase has been attributed to the trend need to make a choice between medications,
toward older childbearing, as the rate of fertil- many rely on the U.S. Food and Drug Admin-
ity for women over 40 has increased approxi- istration (FDA) Pregnancy Categories (see
mately 10%.8 Older women are more likely to Table 7-1 on page 128). Under this system, a OB Safety Tip:
have comorbidities such as hypertension or drug is classified by a pregnancy risk factor, Recognizing Teratogenic
diabetes that are appropriately treated with indicated by one of five letters ranging from Agents
medication. Category A, signifying the lowest risk level for Although most birth defects are
not related to use of medications,
embryonic/fetal harm, to Categories D and X,
some congenital anomalies will
However, even healthy women are more likely indicating known teratogenic or fetotoxic risk.
not occur if a nurse recognizes a
today to use medications than in years past; For Category D drugs, the benefit of treat- teratogenic agent and use of the
sometimes not for their health, but for the health ment may outweigh the risk to the fetus. An agent is avoided.
of their babies. For each medication used, the example is carbamazepine to prevent epileptic
nurse needs to know the effect on both the seizures, which has been linked to increased
mother and the fetus. For example, folic acid risk to the fetus of developing spina bifida.
is routinely recommended prior to conception Category X drugs are always contraindicated
and during the first trimester because women during pregnancy because of a high risk of
who have taken supplemental folic acid just adverse effects for the fetus.
before and during the first several weeks of
pregnancy have demonstrated decreased New methods of categorizing pregnancy.
risk of open neural tube defects in the fetus.9 The FDA Pregnancy Categories shown in
This vitamin is of no particular benefit or risk Table 7-1 have been criticized for unneces-
to the woman. Some women seek remedies sary oversimplification, confusion regarding
for some of the common discomforts of preg- concepts, and lack of clear clinical relevance.
nancy. These conditions, such as constipation, Countries such as the United Kingdom, Ger-
are of little significance to fetal health, but are many, and Australia have other methods of
of concern to the woman, and mild laxatives rating the effect of drugs during pregnancy that
have little if any effect on the fetus. incorporate more detailed information. A new
method of categorization has been advocated
Finally, some conditions pose risks to both that provides a narrative of current research
mother and baby that require careful weighing findings in a manner similar to the Canadian
of benefits and potential hazards of treatment. Mother Risk format but has not yet been
For example, untreated depression is associ- adopted in the United States.11
ated with poor nutrition, smoking, substance
127
Table 7-1. U.S. Food and Drug Administration Pharmaceutical Pregnancy

Categories
Category A Adequate and well-controlled human studies have failed to demonstrate a risk to
the fetus in the first trimester of pregnancy (and there is no evidence of risk in later
trimesters).
Category B Animal reproduction studies have failed to demonstrate a risk to the fetus and there are
no adequate and well-controlled studies in pregnant women. OR Animal studies have
shown an adverse effect, but adequate and well-controlled studies in pregnant women
have failed to demonstrate a risk to the fetus in any trimester.
Category C Animal reproduction studies have shown an adverse effect on the fetus and there are
no adequate and well-controlled studies in humans, but potential benefits may warrant
use of the drug in pregnant women despite potential risks.
Category D There is positive evidence of human fetal risk based on adverse reaction data from
investigational or marketing experience or studies in humans, but potential benefits
may warrant use of the drug in pregnant women despite potential risks.
Category X Studies in animals or humans have demonstrated fetal abnormalities and/or there is
positive evidence of human fetal risk based on adverse reaction data from investiga-
tional or marketing experience, and the risks involved in use of the drug in pregnant
women clearly outweigh potential benefits.
Defined: Teratogenic and

Fetotoxic Drugs Source: U.S. Food and Drug Administration: United States FDA pharmaceutical pregnancy categories. Fed Regist 44:37434–
A teratogenic drug is one that 37467, 1980.
causes a congenital anomaly
when administered during critical
periods of embryonic develop- Drugs and Birth Defects loss that can be absorbed by women who may
ment when specific fetal struc- There is a 3%–5% chance that any fetus will for some reason handle these tablets. Use of
tures are developing. Therefore, have a birth defect or congenital anomaly.12 paroxetine, an SSRI, in pregnancy has been
teratogenic drugs are of highest Drugs are actually the least common etiology of found to be associated with cardiac anoma-
risk to the fetus in the first tri-
birth defects. The vast majority of birth defects lies, although other SSRIs have not.15 Women
mester. The term fetotoxic refers
to fetal insults that occur in the
are of unknown cause, with genetic abnormali- also should be advised that fat-soluble vita-
second and third trimesters. For ties being the second most likely agent. Other mins, such as vitamin A, can be teratogenic in
example, the drug nicotine found causes include maternal disease, infections, large doses. Occasionally, a woman will take
in tobacco is fetotoxic because it and environmental influences, with drugs being prenatal vitamins with iron, and when advised
interferes with fetal growth. the least common of the list.13 Although more to increase iron intake due to anemia, she may
than 90% of drugs currently on the market have simply double or triple her intake of vitamin/
unknown effects on the embryo or fetus, only a mineral capsules daily. These additional cap-
small handful are known to have clear terato- sules or tablets increase her risk of increas-
genic or fetotoxic effects.14 ing her consumption of vitamin A. Table 7-2 on
pages 129–131 lists the drugs most commonly
Most teratogenic drugs such as thalidomide recognized as known teratogens.
have been known for many years. Some
nurses might not be aware of the teratogenic- Pregnancy Influences Drug Metabolism
ity of certain newer drugs such as angiotensin The unique physiological changes in preg-
converting enzyme (ACE) inhibitors, which are nancy affect the usual pharmacokinetics
associated with fetal growth restriction, and and pharmacodynamics of medications (see
finasteride, a treatment for male-pattern hair Chapter 6 on page 113 for a definition of
128
Table 7-2. Commonly Known Teratogenic Drugs
Drug Teratogenic Associations Comments

Androgens and testosterone • Virilization of females • Risk is dose-dependent and based on
derivatives (including • Advanced genital development of critical period (labioscrotal fusion com-
danocrine) males mon before nine gestational weeks).
• Brief exposure is rarely significant.
Angiotensin converting • Growth restriction • Risk of growth restriction is ap-
enzyme (ACE) inhibitors • Oligohydramnios proximately 25%, with fetal morbidity
• Renal failure approximately 30%.
• Decreased skull ossification • Risk of effects increases in second
• Renal tubular dysgenesis and third trimester, most likely due to
decreased uteroplacental flow.
Antithyroid drugs • Fetal and neonatal goiter • Methimazole should be avoided.
• Hypothyroidism • Propylthiouracil is the agent of choice,
• Aplasia cutis (with methimazole) subject to close monitoring because
high doses can affect fetal thyroid.
Carbamazepine • Neural tube defects • Risk of neural tube defect is in-
• Minor craniofacial defects creased, particularly when used with
• Developmental delays other antiepileptic drugs.
• Growth restriction
Warfarin • Bone defects • Risk is 15%–25% when anticoagu-
• Growth restriction lants that impair vitamin K are used,
• Central nervous system (CNS) defects particularly at 6–9 weeks of gestation.
• Developmental delays • Later use in pregnancy is associated
with abruption, CNS defects, stillbirth,
and hemorrhage of the fetus/newborn.
Diethylstilbesterol (not in • Clear cell adenocarcinoma of vagina • Vaginal adenosis is found in 50% of
clinical use in the United and cervix females whose mothers took these
States) • Vaginal adenosis drugs before nine weeks gestation.
• Possible infertility or subfertility in • Data suggest that males exposed in
females and males utero may have up to 25% incidence
of epididymal cysts and abnormal
testes and spermatozoa.
Finasteride • Male genital abnormalities • Marketed as a hair loss treatment for
men, but can be absorbed through
handling broken tablets
Folic acid antagonists • Spontaneous abortion • Includes cytotoxic drugs like aminop-
• Various anomalies terin (not currently in clinical use) and
methotrexate
• Malformation in the first trimester is
30%, among those who survive.
• Some authors include trimethoprim,
triamterene, carbamazepine, phe-
nytoin, phenobarbital, and primidone.
• Some suggest that risk can be de-
creased with folic acid in multivitamins.
(continued)
129
Table 7-2. Commonly Known Teratogenic Drugs (continued)

Lithium • Congenital heart disease (Ebstein) • Low risk
• Exposure in the last month of pregnancy
is linked to toxic effects on thyroid,
renal, and musculoskeletal systems.
Misoprostol • Moebius sequence (brain stem • Not very effective for abortion unless
ischemia, vascular disruption for combined with mifepristone (in the
misoprostol) form of RU 486)
Nonsteroidal • Theorized premature closure of the • Sulindac probably does not have the
anti-inflammatory drugs ductus arteriosus effect on the ductal constriction.
(NSAIDs) • Necrotizing enterocolitis • Also associated with postterm
pregnancy
Phenytoin • Growth restriction • Full syndrome is less than 10% of
• Mental retardation fetuses exposed.
• Craniofacial dysmorphia • Degree of expression may be associ-
ated with a mutant gene that decreas-
es production of epoxide hydrolase,
an enzyme necessary to decrease the
teratogen phenytoin epoxide.
Streptomycin and • Hearing loss • No ototoxicity has been found with
kanamycin • Eighth nerve damage gentamicin or vancomycin.
Tetracycline • Abnormalities of teeth • No known effect unless exposure oc-
curs in second or third trimesters
Thalidomide • Limb deformities • Risk is 20%–30% during critical period.
• Cardiac and GI abnormalities • Used for years before teratogenic
effects became obvious
• Back on market to treat HIV–related
oral lesions, Hansen’s disease, tuber-
culosis, and multiple myeloma
Trimethadione and • Growth restriction • In the first trimester, risk of spontane-
paramethadione • Cleft lip/palate ous abortion is 60%–80%.
• Mental retardation • Characteristic facies is associated
• Facial dysmorphia with use.
• Ophthalmic, limb, and GU problems • These antiseizure drugs are rarely
used today because other drugs are
available.
Valproic acid • Neural tube defects • Incidence is approximately 1%.
• Minor facial defects • Exposure must be in the first trimester,
before closure of the neural tube.
130
Table 7-2. Commonly Known Teratogenic Drugs (continued)

Vitamin A and derivatives • Spontaneous abortion • Use before pregnancy of isotretinoin
• CNS defects is not a risk because it is not stored
• Cardiovascular, facial dysmorphia in tissue.
• Mental retardation • Etretinate has long half-life and may
• Cleft lip/palate present a problem.
Note that 30% of affected infants,
according to the Retinoid Pregnancy
Prevention Program,* are conceived by
women who did not use a contraceptive
method, assuming they were not fertile
because they had not conceived during
a period of months or years when they
had not used contraceptive methods.
• Some exposures through use of
leftover medications, and even a phy-
sician obtaining a drug from a friend
to treat her oily skin, and so on, have
been reported.
*The Retinoid Pregnancy Prevention Program is a joint program sponsored by the U.S. Food and Drug Administration and the manufac-
turer of isotretinoin. Participating prescribers and patients are given strict criteria for prescribing isotretinoin, health education materials for
patients, and qualification checklists that must be filled out before prescriptions are filled.
Source: Adapted from Brucker M.C., Faucher M.A.: Chapter 10, Pharmacology and Midwifery, Table 10-6. In Varney H., Kriebs J.,
Gegor C.L. (eds.): Varney’s Midwifery, 4th ed. Boston: Jones and Bartlett, 2004, pp. 263–264.
pharmacokinetics and pharmcodynamics). Drug Interactions

For the vast majority of drugs, the therapeu- The management of pregnancy also is fre-
tic index is wide enough that customization quently characterized by polypharmacy. Preg-
of dosage is not necessary for a pregnant nant women routinely take vitamins, minerals,
woman. In rare situations, the effect of the and over-the-counter treatments for common
pregnancy requires substantial changes to discomforts. In the majority of cases these
drug treatment. In pregnant women allergic agents pose little risk of severe interactions.
to penicillin who contract syphilis, erythro- However, some pregnant women may have
mycin provides an inexpensive treatment for genetic polymorphisms, genetic variations
the woman herself. However, erythromycin that may place a woman at risk of unex-
passes across the placenta membranes with pected drug reactions, particularly women
great difficulty, if at all. Thus, treatment with with altered metabolism involving the family
erythromycin fails to treat the fetus with a dose of cytochrome P450 enzymes. Just as when
that is adequate to prevent congenital syphilis. two or more drugs are taken by a nonpregnant
Therefore, treatment of syphilis during preg- woman with such a genetic polymorphism, the
nancy has to include penicillin for the sake activity of one drug stimulates or inhibits the
of the fetus and initial desensitization of the CYP450 enzymes, which in turn increase or
woman to penicillin is recommended by the decrease the expected plasma concentration
Centers for Disease Control and Prevention.16 of the second drug. Fortunately, most serious
131
interactions, such as those that occur when maternal satisfaction of less than 50%.19 In the
anti–HIV drugs and oral contraceptives are mid-1950s, opiates were administered orally,
taken concomitantly, are not relevant for preg- and when scopolamine-induced “twilight
nant women. However, in pregnant women sleep” was popular, intramuscular use became
with chronic diseases such as hypertension, popular. Antihistamines such as prometha-
diabetes, or tuberculosis, nurses may be faced zine or hydroxyzine were used either before
with orders to administer unfamiliar drugs. It is or with an opiate because of their sedative
of paramount importance that whenever any and/or anxiolytic effects. Later, when opiates
drug is administered, the nurse be familiar not were administered through the intravenous
only with the expected therapeutic effect but (IV) route for more rapid relief, promethazine
with side/adverse effects, particularly poten- provided some reduction in nausea and vomit-
tially avoidable drug interactions. ing associated with opioid use, but hydroxy-
zine remains contraindicated for IV use. Some
The Mother and Child During nurses and other health care providers feel
that concurrent administration of opiates and
Labor
anxiolytics potentiate each drug’s actions.
In the intensive care environment of the in- However, there is no clear evidence for this
hospital labor and delivery unit, nurses are belief, and there is a possibility that the com-
challenged to constantly multitask while bination leads to a sedated laboring woman
appropriately and safely providing medica- unable to communicate her level of pain.20
tions. Various studies have indicated that, as
in many other areas, safe use of medication Drugs for early labor. For a woman who
can be influenced by provision of continuous presents in prodromal or early latent labor,
labor support for women from doulas and oth- promethazine, hydroxyzine, or prochlorpera-
ers,17 as well as adequate nursing staffing zine have been used for their sedative effects.
patterns.18 In the intrapartum arena, the most Years ago barbiturate sedatives were admin-
common pharmaceutical agents are those istered, but today barbiturates are considered
used to ease labor pain, although remarkable contraindicated because of their prolonged
differences in choice of analgesic drugs often half-life and the ease with which they cross
are apparent from region to region and even the placenta and sedate the fetus/newborn.
OB SAFETY Tip: Intrapartum hospital to hospital. Occasionally morphine sulfate may be admin-
Pain Relief
istered to abort irregular or uncoordinated
Medications for intrapartum pain
vary based on dosing, route, and
Pain Relief: Systemic Analgesics contractions, and the woman will either stop
adverse effects, requiring the For many years systemic opiates were the labor or enter into a regular pattern of uter-
nurse to be well versed in the drugs of choice for the laboring women. The ine contractions. It is assumed the opiate will
specifics of these agents while advantages of specific agents over each other not interfere with active labor progress. When
caring for a woman in distress. have been topics of debate, although with lit- medications are administered for early labor,
tle research evidence to support any stance. women are most likely discharged from a hos-
Among the most common agents that have pital or birth center to home and must have
been used are the following opiates: morphine explicit information regarding when to call or
sulfate, alphaprodine, hydromorphone, nalbu- return. When medications are administered
phine hydrochloride, meperidine, sublimaze, before discharge, the woman must have a
and butorphanol, some of which have fallen safe method to return home because she may
into disuse, or have even been removed from experience sedation.
the market. For example, meperidine once
was the most popular of labor analgesics, Drugs in active labor. A 2011 systematic
but due to lack of pain relief, has a reported review by the Cochrane Collaboration reported
132
more than 54 studies with more than 7,000 the opiates. For some women, systemic anal-
women in active labor.21 These women either gesics are administered early in labor with
received one of two or more opiates or a pla- the intention for regional anesthesia to fol-
cebo in labor. In general, most of the evidence low, and risks of respiratory depression fall as
was of poor quality, and few statistically signifi- the number of hours in labor increase. Con-
cant results emerged. The general conclusion versely, women who are in late active labor
was that parenteral opiates provided some and close to birth may benefit from systemic
pain relief and moderate maternal satisfaction. analgesics because fetal/respiratory depres-
The systematic review failed to find any clear sion is unlikely for an hour after administration,
evidence of fetal adverse effects. Due to limi- by which time the baby will have already been
tations, no single opiate was revealed to pro- delivered.
vide the best analgesia with least side effects.
Opiates: agonist and antagonist effects.

Opiates are categorized by their agonist or Some providers order
antagonist effects on receptors, including different opiates for the
mu and kappa receptors. Pure mu agonists same laboring woman.
include meperidine, fentanyl, and morphine If this is anticipated,
and are associated with an increased risk of the agonist/antagonists
respiratory depression, sedation, and gastro- should not be
intestinal disturbances. Agonist/antagonists
administered first
such as butorphanol are associated with less
because the residual
nausea, vomiting, and sedation. Butorphanol
drug may interfere
has a ceiling effect for its analgesic properties.
with the mu agonist
Although agonist/antagonists are commonly
action of the others.
used agents, they are contraindicated for Defined: Epidural
women who have a history of drug addiction An epidural is an umbrella term
that refers to injecting an anal-
because adverse effects include drug with-
gesic into the spinal anatomy. It
drawal symptomatology due to the antago-
varies by technique used, area of
nism at the mu receptor. Some providers order In conclusion, systemic analgesia continues to spinal anatomy where the drug is
different opiates for the same laboring woman. be used to treat labor pain. For women choos- placed, and the type of medica-
If this is anticipated, the agonist/antagonists ing out-of-hospital care, or in other countries tion administered. For example,
should not be administered first because the where regional anesthesia is rare, opiates are fentanyl may be injected into the
residual drug may interfere with the mu ago- an available option for labor pain relief. epidural space as a bolus or a
continuous infusion or may even
nist action of the others.
be patient controlled. An intrathe-
Pain Relief: Regional Analgesia— cal injection of fentanyl is often
Timing of systemic analgesic pain medica- Epidural referred to as a “walking epidu-
tions. Timing of the administration of systemic Today, epidural analgesia is the most common ral” because it does not cause a
analgesics is a subject of much discussion type of regional analgesia for treating the pain sympathetic block and, therefore,
and usually is the clinical decision of the of labor in the United States. While other types the woman is not limited to stay-
nurse. No specific guidelines exist regard- of regional analgesias, such as paracervical ing in a bed secondary to lower
ing when to administer the agents in order to nerve blocks or pudendal blocks, remain avail- limb partial paralysis.
maximize pain relief and minimize fetal risks. able in certain areas of the country, elsewhere
All opiates have a risk of respiratory depres- there are no providers skilled in their use.
sion for both mother and fetus/newborn. Elec-
tronic fetal heart-rate pattern variations have Local anesthesia and impact on “labor-
been reported to be associated with most of ing down.” Local anesthetics commonly are
133
injected into the epidural space, as they block maternal fever, appears to be of minimal risk
nerve transmission of pain better than opioids. to the fetus, but often results in unnecessary
Depending on the type, amount of medication, invasive testing for the newborn found to be
and concentration, the result may be minimal- “febrile.” With the exception of the walking
to-complete blockage of sensation as well as epidurals, such analgesia/anesthesia can
minimal-to-complete block of motor function. limit maternal movement or the use of water
When a woman experiences anesthesia, par- (hydrotherapy) or other nonpharmaceutical
Ob Safety Tip: Emerging ticularly in the perineal area, she may lose pain relief methods. Use of conventional epi-
Medication Information the sensation of bearing down or the desire durals commonly restrict births to in-hospital
The field of pharmacology to push. Innovative nurses developed the settings. Early concerns that epidurals have
continues to evolve, and many technique of “laboring down” wherein women been associated with untoward outcomes
medications may be commonly rest for a short period between active labor such as increased cesarean section births,
used even though information
and the second stage of pushing. Laboring decreased effective breastfeeding, and other
about long-term effects and
down improves vaginal birth rates and lessens concerns have not been well established. A
effectiveness often is lacking, so
nurses need to always be alert maternal exhaustion. It is increasingly adopted 2011 systematic review called into question
for emerging information. in clinical practice.22 By allowing physiologic the common practice of reserving the method
labor to proceed without aggressive coaching, until the woman’s cervix is dilated to three cen-
the fetus descends and rotates naturally. timeters or more because the review found no
increase in the cesarean section rate when
Local anesthesia toxicity The risk of local women receive an epidural early in labor rela-
anesthetic toxicity is rare but can exist in tive to the more active phase of labor.26
obstetrics when excessive medication is
administered or an unintended intravascular Pain Relief: Regional Analgesia—
bolus occurs. For lidocaine, the maximum Inhalation Anesthetics
safe dose ranges from 4 mg/kg to 7 mg/kg. General anesthesia largely has been replaced
Diagnosis of anesthetic toxicity is made based by regional analgesia. However, one type
on clinical signs such as central nervous sys- remains popular outside the United States:
tem (CNS) disturbance, including seizures, nitrous oxide.
followed by respiratory depression, cardiac
arrest, and death. Once diagnosed, prompt Nitrous oxide. Nitrous oxide is a safe
therapy should be initiated, including ventilator and effective method of analgesia self-
support, anticonvulsants, and cardiac medica- administered by the laboring woman.27 This
tions, as needed. agent is mixed with an equal amount of oxy-
gen and provided through a mask. Women
Epidural side effects. Side effects of obstet- breathe deeply with the onset of contractions
rical epidurals have been reviewed, debated, so that the most intense effect occurs simulta-
and reviewed again.23–25 In general, severe neously with the highest intensity of the con-
adverse effects associated with epidurals tend traction. Because the woman self-administers
to be few, and those that do occur are often the agent, any sedation will cause her to drop
related to the anesthesia technique, including the mask away from her face. Use of nitrous
inadvertent dural puncture, resulting in a sig- oxide has been limited by lack of equipment
nificant postpartum headache; misplacement in many settings and lack of familiarity and
of the catheter, resulting in spinal anesthesia comfort with it among obstetrical providers,
with the risk of respiratory depression; and although it continues to be popular among
possible infection or hematoma. Other, less dentists who liberally use it in office settings,
serious maternal and fetal risks of epidurals and it is popular for laboring women in other
are more controversial. A common condition, industrialized countries. Wider availability of
134
equipment for its use and greater acceptance today. This agent is well established because
may revive its use in the United States. of decades-long use in the treatment of
preeclampsia/eclampsia. More recent studies
Oxygen as a drug. Recent research and the have linked it with a decrease in the incidence
changes in the CPR recommendations from of cerebral palsy, and it is now termed neuro-
the American Heart Association has caused protective or brain sparing.29 Risks with use of
professionals to reassess the use of oxygen. this agent are discussed in the section regard-
Defined: Tocolytic
Oxygen’s relationship with free radicals and ing preeclampsia/eclampsia (see page 136).
Pharmaceutical agents used to
long-known adverse ophthalmic effects with promote uterine quiescence, or
preterm infants are some of the reasons that Beta-adrenergic drugs. Most beta-adrener- suppression of uterine contrac-
liberal use is being reevaluated. At this time, gic drugs (beta-blockers) are no longer used tions (tocolysis), during preterm
it is common to administer oxygen to labor- as tocolytics because of the risk of pulmonary labor are known as tocolytics.
ing women who have any indication of poor edema, particularly when the woman receives
fetal perfusion. However, it should be noted IV fluids. Ritodrine , a beta-adrenergic, and the
that little evidence exists as to this practice. only drug with FDA labeling for tocolysis, was
A Cochrane review published in 2003 noted voluntarily removed from the U.S. market. The
only two studies for evaluation, neither of good other beta-adrenergic, terbutaline, received an
quality, and neither illustrating any benefit for FDA black box warning in 2011 advocating that Ob SAFETY Tip: Elective
Inductions
oxygen administration during labor.28 Research it not be used for long-term tocolysis due to an
Preterm births are most common
on oxygen use during labor is greatly needed. association with serious cardiac disorders.
at 36–38 weeks gestation, and
there is considerable evidence
Special Situation: Tocolytics for Preterm Other tocolytics. Although magnesium sul- against performance of elective
Labor fate is the most common tocolytic, some sites inductions before 39 gesta-
Preterm birth continues to be a major issue in use nifedipine, a calcium channel blocker, and tional weeks.30 Therefore, nurses
obstetrics, including in developed countries. In others use indomethacin, an NSAID. No evi- should be aware of pregnancy
dence exists that one is a better choice than dating criteria and estimating
the United States, one in eight babies is born
gestational age before any elec-
before full term. Most preterm births occur another. Tocolytics are contraindicated when
tive induction is begun.
without any known etiology. Women with a his- the extrauterine environment is healthier for
tory of a preterm birth have been found to be the fetus than intrauterine conditions, such
at a higher risk for a subsequent preterm birth. is the case in chorioamnionitis, fetal growth
restriction, or serious maternal disease.
Tocolytics have been used for decades, yet good
evidence as to effectiveness remains elusive. Special Situation: Induction of Labor
The majority of studies of beta adrenergics, non- In addition to pain medications, the drug most
steroidal anti-inflammatory drugs (NSAIDs), and commonly used during the intrapartum period
calcium channel blockers that have been used is synthetic oxytocin. Oxytocin is used to
for tocolysis have found preterm birth usually is induce labor, augment labor when uterine con-
delayed for 24–48 hours, allowing antenatal ste- tractions are insufficient, and to stop postpar-
roids to be administered. However, long-term tum hemorrhage. Oxytocin is also one of the
effectiveness as well as influence on perinatal 13 named by the Institute of Safe Medication
outcomes, has not been found. Because dehy- Practices (ISMP) as a high-alert drug. Drugs
dration has been associated with preterm birth, on this list are those that have an increased risk
hydration often is the first step to treat potential of causing significant patient harm when used
preterm labor. in error.31 If oxytocin is given in excess, it can
cause tetanic uterine contraction (tachysys-
A neuroprotective tocolytic. Magnesium tole). Tachysystole prevents normal intrauter-
sulfate is the most commonly used tocolytic ine oxygenation, and the fetus may experience
135
decreased oxygen transport. Today, oxytocin opiate poisoning.32 Given the state of the sci-
is administered via an infusion pump that has ence, genetic screening for this rare condi-
safeguards built in to prevent overdoses. tion is unreasonable, but awareness of the
phenomenon has led to recommendations
Special Situations: Preeclampsia/ that women should limit codeine use to two to
Eclampsia three days, and breastfeeding infants should
Interestingly, one of the other 13 drugs on the be observed for signs of CNS depression.33
ISMP list of high-alert medications is magne-
sium sulfate, which is used to stop preterm Other postpartum agents. Perineal sprays,
labor contractions and to prevent seizures in gels, and ointments are associated with rare
women who have preeclampsia during labor. allergic reactions, but pose few serious risks,
Magnesium sulfate inhibits uterine contrac- particularly to the newborn. Lactation suppres-
tions by hyperpolarizing the plasma mem- sants of years ago are no longer commonly
brane and blocking the contraction mechanism used, primarily because of lack of effective-
within the muscle cell. Similarly, this drug pre- ness and multiple side effects.
vents eclamptic seizures. Magnesium sulfate
is exclusively excreted via the kidneys, so Medications for postpartum mood dis-
women must have adequate kidney function orders. Postpartum mood disorders range
to safely take this medication. Perhaps more from what is colloquially termed “baby blues”
important, the therapeutic index of magne- through postpartum depression to postpar-
sium sulfate is extremely narrow. Symptoms of tum psychosis. Multiple risk factors have been
Ob Safety Tip: Clear magnesium toxicity include absence of deep identified but no clear etiology has emerged.
Communication
tendon reflexes, respiratory depression, and For women who have experienced a postpar-
In situations in which mothers
cardiac arrest. tum depressive episode or psychosis before,
and babies are cared for by
separate nurses, the nurses must providers may initiate an antidepressant pro-
communicate clearly with all The Postpartum Period phylactically. No single agent appears to be
members of the health care team the treatment of choice, although research
because some maternal agents Postpartum, or the puerperium, traditionally regarding progesterone therapy has found
still can pose neonatal dangers, has encompassed the first six weeks after that specific hormone not to be effective.34
particularly when the woman is birth. For in-hospital nurses in the United
breastfeeding.
States, postpartum usually connotes the first The Breastfeeding Dyad
one to three days after birth and before hos- Breast is best, a simple mantra with little room
pital discharge. During this time, the most for equivocation. However, just as pharmaco-
common drugs used are those for pain or dis- kinetics and pharmacodynamics vary during
comfort. These agents include systemic anal- pregnancy, the addition of a new physiologic
gesics, perineal topical anesthetics/analgesics compartment, namely the breast and the milk
and the occasional stool softener. it contains, should guide medication manage-
ment. Years ago women who did not wish
A cautionary pharmacogenomic tale. The to breastfeed were administered a lactation
common analgesics include well-established suppressant. Today the major treatment to
agents such as codeine. However, any opiate prevent or treat breast engorgement among
should be used judiciously. A case report from women who desire not to breastfeed is aimed
2006 illustrates a pharmacogenomic issue at symptom relief.
of note. A new breastfeeding mother was an
undiagnosed ultrarapid metabolizer, and The milk/plasma ratio. In an ideal world,
metabolites accumulated in the milk, ultimately drugs could be customized for the maternal-
resulting in a tragic death of the neonate from infant dyad. For example, the milk/plasma ratio
136
often is provided to designate the concentra- SSRIs and breastfeeding. SSRIs have
tion of drugs in breast milk compared with that become the most common drug for depression
in maternal plasma. Listing of this measure- and are gaining popularity when used to avoid
ment provides a false security to providers; significant postpartum psychiatric mood disor-
other factors—including dosing, protein bind- ders. The following agents have been termed
ing, transport of the drug, and even whether or compatible with breastfeeding, although seda-
not the milk is colostrum, foremilk, or hind milk tion and milk interruption may occur: fluox-
with varying amounts of fat—can influence etine, paroxetine, amitriptyline bupropion, and
transfer of a drug through breast milk. desipramine. The drugs doxepin, citalopram,
and escitalopram should be avoided based on
current information.
However, just as Safe lactation drugs. Similar to problems

pharmacokinetics and with categorization of the safety of drugs dur-
pharmacodynamics ing pregnancy, there is no perfect list for the
vary during pregnancy, safety of drugs in lactation. The American
the addition of a Academy of Pediatrics has large tables of
new physiologic various categories for drugs, Hale has another
compartment, namely popular system ranging from L1 (safest) to L5
the breast and the milk (contraindicated), and other methods exist.
it contains, should
guide medication Women may discontinue breastfeeding
management. because of fear that a drug will harm the new-
born. Not only should drugs that are compatible
with breastfeeding be chosen, but health edu-
cation for the woman must include support to
Pain relief for breastfeeding women. Among continue breastfeeding. After all, breast is best.
the most common indications for medications
among breastfeeding women is the need for Drugs and the Newborn
pain relief. Ibuprofen has minimal if any drug Drugs commonly administered to newborns
transfer into the breast milk, making it a good the first hours after life include silver nitrate oph-
choice. Hydrocodone already is in active form thalmic drops and intramuscular injections of
and lacks a metabolite, making it a better vitamin K. Neonatal conjunctivitis or ophthalmia
choice than codeine, which can be problematic neonatorum¸ caused by Neisseria gonorrhea or Ob Safety Tip: Newborns
if the mother is an ultrarapid metabolizer as Chlamydia trachomatis, has been dramatically Newborns are not miniature
described above. Penicillins and cephalospo- decreased over the last several decades sec- adults, and pharmacokinet-
rins have only trace levels in milk, and tetracy- ondary to routine prophylaxis for the newborn’s ics and pharmacodynamics
cline interacts with milk, so little is absorbed by eyes in the first hours after birth. The antibiotic vary based on gestational age,
the infant, suggesting it is safe for short periods agents used have no adverse effects on the chronological age, and general
health.
of time (for example, less than three weeks). newborn. Newborns also are commonly treated
Metronidazole often is avoided or women are with an injection of vitamin K to prevent neo-
advised not to breastfeed for at least 24 hours natal bleeding. The neonate does not possess
after drug administration, not because of per- the adult levels of vitamin K clotting factors for
manent adverse effects to the neonate, but due many months. Infants born to mothers who are
to neonatal gastric side effects with subsequent on anticonvulsant medications, antituberculosis
decreased suckling. drugs, or vitamin K antagonists are at an addi-
tional risk of bleeding.
137
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pharmaceutical agents that are used. Medi- 327:1832–1835, Dec. 24, 1992.
cations offered to pregnant women or women 10. Pearlstein T.: Perinatal depression: treatment
in labor have pharmacologic effects on the options and dilemmas. J Psychiatry Neurosci
woman, fetus, or both. Medications used in 33:302–318, Jul. 2008.
perinatal nursing also need to be assessed for 11. Law R., et al.: FDA pregnancy risk catego-
potential teratogenic or fetotoxic effects, which ries and the CPS: Do they help or are they a
are not reversible. Thus, medication safety in hindrance? Can Fam Physician 56:239–241,
obstetrics has several unique challenges. Mar. 2010.
12. Polifka J.E., Faustman E.M., Neil N.: Weighing
References the risks and the benefits: A call for the empiri-
1. Institute for Safe Medication Practices (ISMP):
cal assessment of perceived teratogenic risk.
ISMP’s List of High-Alert Medications. 2008.
Reprod Toxicol 11:633–640 Jul.–Aug., 1997.
http://www.ismp.org/tools/highalertmedica-
13. Brent R.L.: Environmental causes of human
tions.pdf (accessed Jul. 22, 2011).
congenital malformations: The pediatrician’s role
2. Clark S.L., et al.: Oxytocin: New perspectives
in dealing with these complex clinical problems
on an old drug. Am J Obstet Gynecol 200:
caused by a multiplicity of environmental and
35.e1–35.e6, Jan. 2009.
genetic factors. Pediatrics 113(suppl.):957–968,
3. The Joint Commission: Preventing infant death
Apr. 2004.
and injury during delivery. Sentinel Event Alert
14. van Gelder M.M., et al.: Teratogenic mecha-
30, Jul. 21, 2004. http://www.jointcommission.
nisms of medical drugs. Hum Reprod Update
org/assets/1/18/SEA_30.PDF (accessed Aug. 28,
16:378–394, Jul.–Aug. 2010.
2011).
15. Way C.M.: Safety of newer antidepressants in
4. Ciarkowski S.L., Stalburg C.M.: Medication
pregnancy. Pharmacotherapy 27:546–552, Apr.
safety in obstetrics and gynecology. Clin Obstet
2007.
Gynecol 53:482–499, Sep. 2010.
16. Workowski K.A., Berman S., Centers for
5. Livingston G., Cohn D.: Social and Demo-
Disease Control and Prevention: Sexually
graphic Trends: More Women Without Children.
transmitted diseases treatment guidelines, 2010.
Pew Research Center Publications, Jun. 25,
MMWR Recomm Rep 59:1–110, Dec. 17, 2010.
2010. http://pewresearch.org/pubs/1642/more-
17. Hodnett E.D., et al.: Continuous support for
women-without-children (accessed Apr. 20, 2011).
women during childbirth. Cochrane Database
6. American Academy of Pediatrics Committee on
Syst Rev (2):CD003766, Feb. 16, 2011.
Drugs: Transfer of drugs and other chemicals
18. Wilson B.L., Blegen M.: Labor and delivery
into human milk. Pediatrics 108:776–789, Sep.
nurse staffing as a cost-effective safety interven-
2001.
tion. J Perinat Neonatal Nurs 24:312–319,
7. Mitchell A.A., et al.: Medication use during
Oct.–Dec. 2010.
pregnancy, with particular focus on prescription
19. Bricker L., Lavender T.: Parenteral opioids for
drugs: 1976–2008. , Apr. 21st, 2011 [Epub
labor pain: A systematic review. Am J Obstet
ahead of print].
Gynecol 186 (suppl. Nature):S94–S109, May
8. Sutton P.D., Hamilton B.E., Mathews T.J.:
2002.
Recent decline in births in the United States,
20. Lowe N.K., King T.L.: “Labor.” Chapter 36 in
2007–2009. National Center for Health
King T.L., Brucker, M.C. (eds.): Pharmacology
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for Women’s Health. Boston: Jones and Bartlett, 28. Fawole B., Hofmeyr G.J.: Maternal oxygen
2011. administration for fetal distress. Cochrane Data-
21. Ullman R., et al.: Parenteral opioids for mater- base Syst Rev (4):CD000136, 2003.
nal pain relief in labour. Cochrane Database Syst 29. Reeves S.A., Gibbs R.S., Clark S.L.: Magnesium
Rev (9):CD007396, Sep. 8, 2010. for fetal neuroprotection. Am J Obstet Gynecol
22. Roberts J., Hanson L.: Best practices in second 204:202.e1–202.e4, Mar. 2011.
stage labor care: Maternal bearing down 30. ACOG Committee on Practice Bulletins—
and positioning. J Midwifery Womens Health Obstetrics: ACOG Practice Bulletin No. 107:
52:238–245, May–Jun. 2007. Induction of labor. Obstet Gynecol 114(pt.
23. Leighton B.L., Halpern S.H.: The effects of 1):386–397, Aug. 2009.
epidural analgesia on labor, maternal, and 31. Simpson K.R., Knox G.E.: Oxytocin as a high-
neonatal outcomes: A systematic review. Am J alert medication: Implications for perinatal
Obstet Gynecol 186(suppl. Nature):S69–S77, patient safety. MCN Am J Matern Child Nurs
May 2002. 34:8–15, Jan.–Feb. 2009.
24. Lieberman E., O’Donoghue C.: Unintended 32. Koren G., et al.: Pharmacogenetics of morphine
effects of epidural analgesia during labor: A poisoning in a breastfed neonate of a codeine-
systematic review. Am J Obstet Gynecol 186:S31– prescribed mother. Lancet 368:704, Aug. 19,
S68, May 2002. 2006.
25. O’Hana H.P., et al.: The effect of epidural 33. Madadi P., et al.: Pharmacogenetics of neona-
analgesia on labor progress and outcome in tal opioid toxicity following maternal use of
nulliparous women. J Matern Fetal Neonatal codeine during breastfeeding: A case-control
Med 21:517–521, Aug. 2008. study. Clin Pharmacol Ther 85:31–35, Jan.
26. Wassen M., M. et al.: Early versus late epidural 2009.
analgesia and risk of instrumental delivery in 34. Dennis C.L., Ross L.E., Herxheimer A.: Oestro-
nulliparous women: A systematic review. BJOG gens and progestins for preventing and treating
118:655–661, May 2011. postpartum depression. Cochrane Database Syst
27. Volmanen P., Palomäki O., Ahonen J.: Alterna- Rev (4):CD001690, Oct. 8, 2008.
tives to neuraxial analgesia for labor. Curr Opin
Anaesthesiol, 24:235–241, Jun. 2011.
139
FOCUS
Patient Education:
Educating Parents About Infant Formula Preparation
Infants are a particularly vulnerable pediatric population. It has been found that health care
providers do not adequately educate parents on how to prepare and store infant formula safely.1
To evaluate a parent’s understanding of these important procedures, nurses can ask the fol-
lowing questions and provide education to help ensure that parents prepare and store infant
formula safely1,2:
• Q: How will you sterilize your baby’s bottles between uses?
A: Use boiling water or an electric dishwasher in a country with a safe and chlorinated water
supply.
• Q: What type of water will you use to prepare your infant’s formula?
A: Distilled or filtered water is best because well water can have high levels of nitrates and
must be tested periodically, tap water may contain fluoride (not to be given to infants under
6 months), and bottled water may have additional vitamins and minerals not necessary for
infants.
• Q: How will you prepare your infant’s formula?
A: Use boiling water that is at least 158ºF (70ºC) and follow the package instructions.
◦ Q: Do you understand what can happen if you give infant formula that is too
concentrated?
A: Dehydration, diarrhea, and excessive intake of calories.
◦ Q: Do you understand what can happen if you give infant formula that is too diluted?
A: Inadequate intake of calories and nutrients, as well as the potential for water intoxica-
tion leading to hyponatremic seizures and cerebral edema.
• Q: How will you test the formula to ensure that it is the right temperature for your baby
before feeding?
A: Drip a drop onto the inside of your wrist and ensure that it is lukewarm.
• Q: How long will you wait to throw away the formula that has been left standing?
A: Two hours.
• Q: If you make formula for your baby ahead of time, how will you store it?
A: Let it cool, then place in the refrigerator, and ensure that it is used within 24 hours.
Nurses can also provide parents with a readable and well-illustrated handout from the
World Health Organization: How to Prepare Formula for Bottle-Feeding at Home
(http://www.who.int/foodsafety/publications/micro/PIF_Bottle_en.pdf ).
References
1. Labiner-Wolfe J., Fein S.B., Shealy K.R.: Infant formula-handling education and safety. Pediatrics
122(suppl. 2):S85–S90, Oct. 2008.
2. Hancock M.E., Brown J.: Formula-feeding safety: What nurses need to teach parents who choose to
formula-feed. Nurs Womens Health 14:302–309, Aug. 2010.
140
CHAPTER EIGHT Medication SAFETY:
Considerations for Oncology
AUTHOR: Kristen Maloney, M.S.N., R.N., A.O.C.N.S., Hospital of the University of Pennsylvania, Philadelphia
Oncology nurses play a critical role in medi- cancer becomes a chronic condition, and
cation management and medication safety for patients’ ongoing treatment needs become
patients being treated for cancer. Ensuring similar to those seen in diabetes or heart dis-
medication safety for the oncology patient is ease. A third path is palliative care, which aims
complicated by special challenges. Oncology to manage the symptoms of cancer without
patients frequently receive multiple medica- the possibility of disease cure or control.2 Pal-
tions (often referred to as protocols or regi- liation reduces symptoms and manages their
mens), including high-alert agents, and are effects, with an overall goal of improved quality
at risk for medication errors that may entail of life for both patient and family.2
serious consequences. Understanding the
complexities of medication safety in oncol- Keeping in mind distinctions among cancer-
ogy requires knowledge of the various types treatment goals allows the oncology nurse
of cancer, treatment goals, characteristics of to successfully manage medications used in
antineoplastic agents and their administration, treating a particular patient and, more impor-
ө
and standards for their administration, as well tantly, fosters better care for the whole patient.
as strategies to optimize nurse competence
and to engage patients and families in safe Antineoplastic Medications as
medication management.
High-Alert Medications
Treatment Goals for Oncology The Joint Commission’s National Patient
Safety Goal 3 states, “Improve the safety of
Patients
using medications,” and Joint Commission
The initial goal of cancer treatment is to rid the International’s International Patient Safety
body of all cancerous cells and achieve cure.1 Goal 3 targets high-alert medications: “The
Cure often takes years of therapy, depending organization develops an approach to improve
on the type of cancer, and commonly requires the safety of high-alert medications.” Nurses
chronic intermittent or even continuous ther- are attuned to the idea of antineoplastic
apy with antineoplastic agents, in addition to agents as high-alert medications, a category
other therapeutic modalities and medications that also includes such drugs as intravenous
for supportive care. When cure is not possible, (IV) potassium chloride and insulin.3,4 Antineo-
the focus of cancer treatment may change. By plastic medications include chemotherapeutic,
using different treatment regimens employing biotherapeutic, and targeted agents. There
chemotherapy, including targeted agents, bio- are a number of reasons why antineoplastic
therapy, radiotherapy treatments, and surgery, agents are categorized as high-alert medica-
it may be possible to control the disease in the tions. According to Schwappach and Wernli,5
sense of decreasing tumor volume and reduc- many chemotherapeutic drugs have a nar-
ing the cancerous cell burden.1 In these cases, row therapeutic window, meaning that they
141
can be toxic to patients even at therapeutic Safety Processes for

doses. Antineoplastic regimens used to treat Antineoplastic Agents
oncology patients are very complex, com-
monly including several antineoplastic agents Antineoplastic agents carry clear benefits;
and other drugs such as corticosteroids used ensuring that the patient experiences them
for premedication to mitigate toxicity or side requires careful attention to safety practices.
effects. In addition, the calculation of doses of Safety procedures for the administration of
antineoplastic agents is based on several fac- antineoplastic agents are in place at most
tors, including body-size area and laboratory institutions providing cancer care and are
results.6 Patients being treated for cancer may often specific to inpatient and outpatient set-
Defined: Templates
also experience toxicities that result in physi- tings. The standards and the procedures that
A template is defined as “an
ological impairments, such as impaired immu- operationalize them are intended to protect
order set without patient-specific
information.” 9 (p. x) Templates nocompetence, which potentiate the risk for or both patients and health care providers.
are most often devised from severity of consequences.
research, standards guidelines, Using a Template
and institution protocols.9 A Medication Errors Involving Order templates (also known as preprinted
template incorporates standards Antineoplastic Agents orders, or PPOs) provide important safety
for dosing and administration, With greater complexity comes greater poten- features to promote medication management
as well as guidelines for related
tial for error. Indeed, antineoplastic agents are in oncology. In one institution, for example,
orders used to avoid or reduce
among the drugs most commonly associated a templated antineoplastic order-set system
toxicity and side effects, such
as those for hydration or sup- with medication errors.5 A study of medica- was developed to assist in reducing medica-
portive medications.9 High- and tion errors completed in Israel, for example, tion errors and increasing patient safety in the
low-dose limits are commonly revealed that the department of hematology- delivery of these agents.9 Specific elements of
included, as are parameters oncology had the highest medication error such templates include streamlined order sets,
for administration, such as rate.7 Historically, medication errors in cancer allowing prescribers to readily identify what
laboratory values to ascertain care have been the impetus for various safety agents they are ordering and for whom they
immunocompetence or radiologic
initiatives on a national scale. The errors that are prescribing them. Generally, elements of
studies to ascertain disease
triggered the initiatives were widely publi- a template encompass clear identification of
status. Although templates
guide prescribers to ensure cized, high-profile events. In 1994, at an aca- the patient and treatment plan, including the
safe medication orders, they are demic oncology treatment center, two patients specific chemotherapeutic regimen, criteria to
also helpful to other members being treated for breast cancer were given be met before administration of medications
of multidisciplinary teams. They large overdoses of a standard chemotherapy (such as laboratory values), and orders for
assist pharmacists and nurses in regimen.8 One of these patients died as the chemotherapy, hydration, and supportive care
safely filling orders and delivering
result of a cyclophosphamide dose four times that also include particular parameters, such
prescribed medications without
greater than she should have received based as dose limits.9 Research suggests that the
errors.
on dose calculations. The other patient suf- use of templated order sets may reduce the
fered irreversible cardiac damage. These two potential for error by decreasing the number
events led to widespread national agreement of order changes required after the prescriber
that dramatically enhanced safety precautions signs off on the original orders.9
for the management of antineoplastic medica-
tions were urgently needed.8 As a result, since Multidisciplinary Approach
1994, the standards for safe antineoplastic A multidisciplinary approach promotes sus-
drug management, particularly drug admin- tainable safe medication management in can-
istration, have been markedly different from cer care. Although templated order sets are
other drug classes. critical in reducing prescribing errors, order
verification and correction further reduce med-
ication errors by lessening the possibilities
142
CHAPTER EIGHT: Medication Safety: Considerations for Oncology
for mistakes at the point of administration by eliminates medication errors; tools like CPOE
nurses. The pharmacist also plays a key role only offer additional means to advance the
in this multidisciplinary approach as the team goal of safety.12 (For more information on how
member who verifies and corrects medication technology can help nurses ensure medication
orders. However, Hoppe-Tichy,10 in a review of safety, see Chapter 2.) Delivery of antineo-
a survey from 85 different nations, showed that plastic agents to patients remains complex,
only 51% of health care providers in hospitals requiring scrutiny to protect patients, and
had 24-hour-a-day, 7-day-a-week access to a involves hazardous agents, mandating special
pharmacist.10 Pharmacists are likely among administration standards and procedures. Relevant Requirements
the most vital members of the multidisciplinary The importance of the safe han-
team, given the increasing use of antineoplas- Safe Handling Guidelines dling of hazardous medications
is reflected in Joint Commission
tic agents and the complexity of regimens. Antineoplastic agents, in addition to being
Medication Management (MM)
classified as high alert, are hazardous drugs.
Standard MM.01.01.03, which
Applying Technology The National Institute for Occupational Safety states, “The organization safely
In recent years, a variety of technologic and Health (NIOSH) classifies drugs as haz- manages high-alert and hazard-
tools, including computerized provider order ardous if they meet at least one of the fol- ous medications.”
entry (CPOE) systems, electronic medication lowing criteria: carcinogenicity, teratogenicity
administration records (eMARs), handheld or or other developmental toxicity, reproductive
otherwise mobile computers, bar coding medi- toxicity, organ toxicity at low doses, or geno-
cation administration systems (BCMAs), com- toxicity. Drugs similar in structure or toxicity
puterized decision support systems (CDSSs), to compounds classified as hazardous using
and automated dispensing machines (ADMs), the above criteria are also considered haz-
have advanced medication safety in cancer ardous by NIOSH standards.13 Consequently,
care. For example, CPOEs improve commu- antineoplastic agents require specialized safe
nication and collaboration among health care handling guidelines. For more on this topic,
providers and their patients receiving treat- see “Exposure to and Safe Handling of Haz-
ment for cancer. Although some organiza- ardous Drugs” on pages 146–148.
tions have experienced challenges applying
CPOE in the specific setting of chemotherapy Look-Alike/Sound-Alike Medications
(because many eMAR systems are not adept Look-alike/sound-alike (LASA) antineoplastic
at handling the chemotherapy work flow), agents are common. There are many LASA
other organizations have found that these sys- pairs in different drug categories, and as in
tems reduce or eliminate the need for written other treatment areas, to help prevent errors
chemotherapy order transcription—a high-risk with antineoplastic agents, it is imperative
aspect of conventional chemotherapy man- that health care providers, including nurses,
agement. CPOE systems have certainly been distinguish between the two drugs in each of
effective in reducing medication errors in gen- these LASA pairs. Examples of LASA medica-
eral: In one study, implementation of a CPOE tions used in oncology include gemcitabine
system decreased medication errors by 40%.11 and capecitabine, mitomycin and mitoxan-
CPOE use easily incorporates template order trone, nelarabine and Navelbine®, cisplatin
sets and facilitates systematic order review and carboplatin, and vincristine and vinblas-
by pharmacists and nurses. Nevertheless, tine, to name only a few. To reduce the risk of
even with technological advancements like error—as well as the potential risk of exposure
CPOE and template order sets, preparation to hazardous materials—precautions must
and administration of antineoplastic and other begin with preparation and continue through
medications used in cancer care still require transporting and administration.14 (See “Stan-
the utmost vigilance by nurses. No technology dards Related to Delivery Routes” on pages
143
145–146 and “Exposure to and Safe Handling chemotherapy inpatients examined patients’
of Hazardous Drugs” on page 146–148.) In experiences related to administration of che-
2004 the Institute for Safe Medication Prac- motherapy. Results revealed that patients
tices (ISMP) estimated that more than half of want to be involved in the chemotherapy
medication errors were due to LASA pairs. In practices to improve their safety and care.5
2005, for example, the ISMP reported a case Similarly, Schwappach and Wernli found that
Joint Commission Medica- of confusion related to “rubicin” chemother- nurses believed involving patients in chemo-
tion Management Standard apy agents. A patient received daunorubicin therapy administration safety was important.15
MM.01.02.01 states, “The organi- instead of the prescribed idarubicin. A nurse
zation addresses the use of look- identified the error, noting the color of the drug
alike/sound-alike medications.” previously administered was different from the
color of the drug about to be administered.14 Involving patients and
In this close call, there was obvious confusion families in preventing
between medication names. Only careful scru- medication errors is
tiny on the part of the nurse during administra- recognized as a key
tion prevented a serious medication error. strategy for success in
studies from around
Continuing Education/Staff the world.5
Development
Because of the ever-expanding treatment
options in cancer care and the large number
of new chemotherapeutic agents, all nurses— Useful strategies for engaging patients
regardless of their experience and level of and families in the prevention of medica-
expertise—need specific education to admin- tion errors. Strategies to advance patient and
ister oncology medications safely. Sheridan- family involvement in safe medication man-
Leos compared current oncology education agement identified in the literature include the
for novice nurses with a redesigned educa- following:
tional plan with specific focus on the care of • Review the treatment plan with the patient
the oncology patient for new nurses in a mid- on each visit.
sized community hospital in the United States. • Read medication labels with the patient to
This study showed that providing nurses with ensure correct medication, patient name,
current, evidence-based information regard- and birth date.
ing antineoplastic treatment contributed to • Educate the patient about notifying the
a decrease in the risk of medication errors.3 nurse if any burning, redness, or swelling
Specific topics in the redesigned educational occurs at the IV site.
plan included sharing errors as a learning • Teach the patient about adverse reactions
opportunity, identifying LASA medications, cal- using the teach-back method; that is, make
culating absolute neutrophil count, explaining certain the patient can explain adverse
error reporting systems used in the institution, reactions to the nurse after being taught
and understanding risks of hazardous drugs.3 them.
• Give the patient opportunities to ask
Involvement of Patients and Families in questions.
Error Prevention • Assure the patient that involvement in his or
Involving patients and families in prevent- her own care is valuable.5
ing medication errors is recognized as a key
strategy for success in studies from around Despite the value of patient and family
the world.5 For example, a Swiss study of 479 involvement, there is a key potential difficulty:
144
Schwappach and Wernli noted that patients the trash or disposed of in the toilet.17 Although
and family members, given the complexity topical antineoplastic agents are not commonly
of cancer treatment, may have limited ability used, safe handling techniques are important
to comprehend the treatment plan as well as for both the patient and the nurse. For exam-
the side effects that may be associated with ple, carmustine (BCNU) is an agent commonly
an adverse reaction.15 Nevertheless, engag- administered topically as a treatment for myco-
ing patients and their family members in pre- sis fungoides.18 Nurses using BCNU should
venting errors during antineoplastic agent don gloves, use gauze to apply the topical
treatment is important and promotes optimal agent to the patient’s skin, and avoid contact
clinical outcomes for those patients who are with eyes and mucous membranes.18 (See also
involved in this fashion. “Exposure to and Safe Handling of Hazardous
Drugs” on pages 146–148.)
Standards for Antineoplastic
Intracavitary routes. Antineoplastic agents
Therapy
delivered via intracavitary means can be
The Oncology Nursing Society (ONS) and the introduced into the body cavity in a variety of
American Society of Clinical Oncology (ASCO) ways, including intrathecal, intraperitoneal,
provide jointly developed specific standards intrapleural, or intravesicular routes.19 Each of
for antineoplastic administration, accepted these delivery options directly applies the anti-
as national guidelines. The standards were neoplastic agent to cancerous cells present in
developed to maintain safe practices, reduce a specific body cavity. For instance, intraperi-
the risk of errors, and increase efficiency.16 The toneal administration instills an antineoplastic
guidelines address staffing-related standards, agent, such as cisplatinum, into the abdominal
chart documentation standards, general che- cavity.19 Intracavitary delivery routes require
motherapy practice standards, chemotherapy safe handling procedures specific to the body
order sets, drug preparation, patient consent cavity and delivery device.
and education, chemotherapy administration,
and monitoring and assessment. It is impor- IV routes. Intravenous therapy is used to
tant to note that the standards clearly state deliver antineoplastic agents in both inpatient
that only specially trained practitioners may and outpatient settings and is among the most
deliver chemotherapy.16 commonly used routes of administration.19
Patients may have peripheral IV lines or cen-
Standards Related to Delivery Routes tral venous lines, depending on the prescribed
In addition to general standards for antineo- regimen, frequency of therapy, and prescriber
plastic agent therapy, the ONS/ASCO stan- and patient preference. Specific guidelines for
dards address administration of antineoplastic peripheral administration that should appear
medication through various delivery routes: in institutional policies include use of a periph-
oral, topical, intracavitary, and intravenous. eral IV line with a dwell time of less than 24
hours, positive blood return, and confirmation
Oral and topical routes. Antineoplastic agents of patency and placement (through verifica-
administered via oral or topical routes are con- tion of blood return) before administration of
sidered hazardous medications; safe handling any antineoplastic agent.19 Metal IV catheters
practices must be maintained to ensure both or “butterfly” needles should not be used for
patient and clinician safety. Safe handling of vesicant administration (see next section),
oral chemotherapy medications stipulates that because they may easily traumatize veins.
the nurse should not crush or break tablets, Plastic IV catheters should be utilized for all
and oral medication should not be placed in vesicant administration.20
145
Vesicant infusion/injection. Vesicant antineo- drugs under study in their urine.24 Safe han-
plastic agents are those that have potential to dling practices are essential to safe nursing
extravasate (leak) into tissue surrounding the practice, given the hazardous nature of anti-
vein through which the agent is administered. neoplastic agents and the potential for expo-
Extravasation is among the most serious com- sure—and such practices will become even
plications of antineoplastic therapy, an avoid- more important in the future. As the U.S. popu-
able error with the potential for tissue necrosis lation continues to age, the number of cancer
requiring long term care, including surgical cases is expected to increase twofold by 2050.
reconstruction.21 Measures to prevent extrav- This change in the epidemiology of cancer will
asation include careful prior assessment of likely lead to the increased use of antineoplas-
intravenous access, confirming blood return tic agents, which will heighten exposure risks
prior to administration, checking for blood for nurses and other health care workers.23
return during administration, and reviewing
signs and symptoms of extravasation with the
patient.22 Specific signs and symptoms are
redness, swelling, burning, or other discomfort Safe handling practices
at the IV site and leakage around the IV site. are essential to safe
Vesicants may be administered through either nursing practice, given
central or peripheral IV lines. However, vesi- the hazardous nature
cant infusions greater than 60 minutes should of antineoplastic agents
be delivered through a central line.20 and the potential for
exposure—and such
Exposure to and Safe Handling practices will become
even more important
of Hazardous Drugs
in the future.
During World War I, scientists discovered
that soldiers exposed to the chemical warfare
agent mustard gas experienced bone mar-
row suppression and illness. This discovery Martin and Larson surveyed members of the
led Karnofsky and colleagues to use nitro- ONS to gather data on the safe handling of
gen mustard to treat hematological and other antineoplastic agents in the outpatient setting.
malignancies.23 Since that time, the use of They found increasing availability of personal
hazardous agents like nitrogen mustard as protective equipment (PPE) for safe handling
antineoplastic drugs has become extensive. at that time in 2003, a trend that has contin-
ued. PPE is now ubiquitous in cancer care set-
Health Care Workers’ Exposure to tings.25 Martin and Larson found that the use of
Hazardous Drugs gloves when administering hazardous agents
Exposure to hazardous drugs has been stud- increased compared with previous studies.25
ied under specific conditions in various health
care areas. For instance, research conducted Use of PPE. The Occupational Safety and
in three U.S. cancer centers examined the Health Administration (OSHA), ONS, and
effects on nurses and pharmacists of exposure NIOSH all have guidelines on the safe han-
to five hazardous drugs. Findings confirmed dling and management of hazardous medica-
contamination by those drugs in pharmacy tions. These guidelines recommend specific
and nursing practice areas.24 Of 68 health processes for storage, preparation, admin-
care workers who had sustained exposure, istration, and disposal of hazardous drugs.
3 were found to have concentrations of the PPE is the first step in the safe handling of
146
hazardous drugs. The recommendations for the past, chemotherapy was often transported
PPE include the use of gloves, gowns, res- to clinical areas without primed lines attached
pirators, and eye and face protection. Gown to the doses. Although current practice stan-
and gloves are recommended for all handling dards indicate that priming during the prepa-
of hazardous medications. Gloves should be ration process is preferable, many practice
disposable and approved for use with these settings do not have facilities that permit it.
types of medications.13,16,26 NIOSH and OSHA Consequently, nurses should be prepared to
Chemotherapy Gloves
recommend double gloving for all handling of prime tubing with normal saline or an equiva-
In the United States, the Food
hazardous agents.13,26 Gowns must be dis- lent compatible IV fluid.
and Drug Administration (FDA),
posable and made of low-permeability fabric. an agency of the U.S. Depart-
Respirators are to be used when cleaning Closed-system delivery devices. Closed- ment of Health and Human
hazardous spills. Eye and face protection is system delivery devices for the administration Services, certifies gloves
recommended as a defense against poten- of hazardous drugs significantly enhance pro- marketed for chemotherapy use
tial splashes. PPE should be examined for tection and further limit the risk of exposures (chemotherapy gloves). 27
any damage during donning and then reex- during the spiking of IV bags and priming at the
amined during removal to detect unnoticed time of administration. Several multinational
exposures.13,16,26 companies produce closed-system delivery
devices; these devices are being increasingly
Use of a biological safety cabinet. Hazard- adopted in U.S. oncology treatment centers. Defined: Closed-System
Device
ous drug preparation requires the use of a
A closed-system device is a drug
biological safety cabinet, which should provide Safe disposal. Disposal of materials after
transfer apparatus that prevents
vertical laminar airflow with a high-efficiency administration to the patient is the final phase exposure to hazardous drugs
particulate air (HEPA) filter and should con- of safe handling. All contaminated bags, bot- because of leaking or aerosoliza-
tain a blower that operates continuously.19,28 A tles, lines, and PPE should be disposed of tion. A closed-system contains
2003 ONS survey revealed that 49% of nurses in a hazardous waste container that is read- hazardous agents within a reser-
reported that pharmacists were preparing their ily available at the location of chemotherapy voir such as an IV bag or bottle
drugs, whereas 49% of nurses reported that administration.29 IV tubing should not be dis- and has an integral delivery line
that contains self-sealing ports.
they were preparing hazardous drugs them- connected from the reservoir or reused for
Closed-system devices may re-
selves.24 Although the trend toward pharma- other drug infusions. A spill kit should also be
duce the risk of hazardous agent
cist preparation has likely continued, use of a readily available in the event of an accidental exposure to health care work-
biological safety cabinet is essential regard- exposure or spill.13,16,26 The American Society ers—who prepare, administer,
less of which professionals are involved or the of Hospital Pharmacists initially recommended and dispose of these drugs—by
which setting is the site of drug preparation. use of spill kits in 1990; the practice remains limiting the potential for disrupted
part of safe handling standards. An antineo- administration devices.
Administration safety measures. Adminis- plastic spill kit should include two pairs of dis-
tration safety measures are required after the posable gloves, low-permeability protective
hazardous drugs are safely mixed and trans- garments, safety glasses, a respirator, absor-
ported to the site for administration. According bent spill pads, disposable towels, hazard-
to ONS, NIOSH, and OSHA, the nurse should ous waste bags, a disposable scoop for glass
always wear PPE, specifically gloves and a fragments, and a puncture-resistant container
gown. A respirator should be donned when the to dispose of glass fragments.30 Institutional
chemotherapeutic agent may become aerosol- policy should specify spill management pro-
ized, such as in a spill. Face and eye protection cesses and should further designate and
are required when a splash risk exists. Critical train professionals in hazardous drug spill
actions include working below eye level and management.
preattaching and priming needles, syringes,
and tubing with Luer lock connections.13,16,26 In
147
Patient and Family Education on Safe error prevention and the safe handling of anti-
Handling neoplastic agents at home.
With the increasing trend toward home admin-
istration of oral antineoplastic agents, nurs- References
ing practice now includes educating patients 1. Sausville E.A., Longo D.L.: Principles of cancer
and their family members about safe handling treatment. In Fauci A.S., et al. (eds.): Harrison’s
practices. Nurses should instruct patients and Principles of Internal Medicine, 17th ed. New
families to follow institutional guidelines for York: McGraw-Hill, 2008, pp. 514–533.
safe handling. In addition to provisions that 2. Choo J., Hutchinson A., Bucknall T.: Nurses’
apply in institutional settings, nurses should role in medication safety. J Nurs Manage
instruct patients and families that antineoplas- 18:853–861, Oct. 2010
tic agent trash should be kept away from pets 3. Sheridan-Leos N.: A model of chemotherapy
and children and that bed linens and towels
education for novice oncology nurses that
as well as clothing potentially contaminated
supports a culture of safety. Clin J Oncol Nurs
by these agents should be machine-washed
11:545–551, Aug. 2007.
separately in hot water.19 Double flushing
4. Institute for Safe Medication Practices (ISMP):
toilets after patient use is also suggested,
ISMP’s List of High-Alert Medications. 2008.
although there is currently no literature that
http://www.ismp.org/tools/highalertmedications.pdf
supports this practice.19 Finally, when edu-
(accessed Aug. 28, 2011).
cating patients and families on safe handling
5. Schwappach D.L., Wernli M.: Chemotherapy
practices, nurses should encourage them to
call their treating clinicians with any questions patients’ perceptions of drug administration safety.
that may arise while at home. J Clin Oncol 28:2896–2901, Jun. 10, 2010.
6. Gandhi T.K., et al.: Medication safety in the
ambulatory chemotherapy setting. Cancer
Conclusion
104:2477–2483, Dec. 1, 2005.
Caring for oncology patients is both reward- 7. Schwappach D.L., Wernli M.: Medication
ing and challenging, in part because the errors in chemotherapy: Incidence, types and
medication management for this particular involvement of patients in prevention. A review
patient population is complex. Meticulous of the literature. Eur J Cancer Care (Engl)
medication management and error preven- 19:285–292, May 2010.
tion are key factors in achieving patient safety 8. Grant S.M.: Who’s to blame for tragic error? Am
in cancer care. Nurses play a critical role in J Nurs 99:9, Sep. 1999.
the multidisciplinary approach needed for 9. Dinning C., et al.: Chemotherapy error reduc-
safe medication management in oncology. tion: A multidisciplinary approach to create
Continuing professional education—updat- templated order sets. J Pediatr Oncol Nurs
ing nurses on developments in antineoplastic 22:20–30, Jan.–Feb. 2005.
agent administration—is also vital to ensure 10. Hoppe-Tichy T.: Current challenges in Euro-
that practice meets national and international pean oncology pharmacy practice. J Oncol
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Pharm Pract 16:9–18, Mar. 2010.
their patients, and for their own well-being
11. Hidle U.: Implementing technology to improve
and that of other health care workers, nurses
medication safety in healthcare facilities:
administering antineoplastic medications must
A literature review. J N Y State Nurses Assoc
be personally committed to the safe handling
38:4–9, Fall 2007–Winter 2008.
of these medications. Finally, nurses play an
12. Schulmeister L.: Ten simple strategies to
absolutely crucial role in educating and engag-
prevent chemotherapy errors. Clin J Oncol Nurs
ing patients and family members in medication
9:201–205, Apr. 2005.
148
13. U.S. Department of Health and Human 22. Schulmeister L.: Preventing and managing
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tic and Other Hazardous Drugs in Healthcare 23. Connor T.H., McDiarmid M.A.: Prevent-
Settings 2010. Publication No. 2010−167. Sep. ing occupational exposures to antineoplastic
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2010-167/pdfs/2010-167.pdf (accessed Aug. 56:354–365, Nov.–Dec. 2006.
10, 2011). 24. Connor T.H., et al.: Evaluation of antineoplastic
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Feb. 2006. Environ Med 52:1019–1027, Oct. 2010.
15. Schwappach D.L., Hochreutener M.A., Wernli, 25. Martin S., Larson E.: Chemotherapy-handling
M.: Oncology nurses’ perceptions about involv- practices of outpatient and office-based oncol-
ing patients in the prevention of chemotherapy ogy nurses. Oncol Nurs Forum 30:575–581,
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16. Jacobson J.O., et al.: American Society of & Health Administration: OSHA Technical
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18. Zackheim H.S.: Topical carmustine (BCNU) in http://www.fda.gov/MedicalDevices/Device-
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20. Sauerland C., et al.: Vesicant extravasation part 29. Nixon S., Schulmeister L.: Safe handling of
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Nov. 27, 2006.
149
FOCUS
Oral Chemotherapy Outside the Hospital Setting
As chemotherapy and other cancer care services transition from the hospital to ambulatory
care, home care, and long term care, these health care settings have had to create new proto-
cols, implement training in-services, and find ways to reduce risks associated with these new
services. The increased availability of oral chemotherapy medications has helped transition
cancer care services to nonhospital health care settings as well as to the home. However, oral
chemotherapy regimens are complex because dosing is frequently based on clinical changes
and body surface area. In addition, medication regimens can be complicated because taking
the medications may be restricted to certain days of the week or month as well as before or after
meals.1,2 Furthermore, systems to prevent outpatient medication errors with oral chemotherapy
have been lacking due to fragmented care, ineffective processes for reporting medication errors,
and communication problems among providers and between providers and patients.2
Even if oral chemotherapy medications are administered safely and correctly, patients need to
be monitored closely to watch for and reduce the severity of adverse drug effects.1,2 Monitor-
ing is also necessary when doses are changed because oral chemotherapy medications have a
narrow therapeutic index, wherein a small increase in the dose can lead to a large increase in
the severity of adverse effects and a small decrease in the dose can lead to therapeutic failure.
Strategies for Oral Chemotherapy in Settings Outside the Hospital

The following safety strategies can be implemented when oral chemotherapy medications are
used in health care settings outside the hospital:
• Use Daily Orders: Have physicians write only one chemotherapy order for the day of admin-
istration (rather than initially writing out the patient’s entire chemotherapy regimen for
several months and then modifying the orders on the actual day of administration follow-
ing a review of laboratory results and any symptoms reported by the patient).2 This simple
change reduces confusion between old and new orders for chemotherapy medications.
• Employ Supportive Technology: Use computerized provider order entry (CPOE) and CPOE
with clinical decision support systems (CDSSs) or preprinted order sets (PPOs), or tem-
plates, to ensure that providers are following protocols when prescribing chemotherapy
(see Chapter 8).1 Have physicians avoid handwritten prescriptions and abbreviations and
provide an indication for use or diagnosis to help pharmacists improve their assessment of
the appropriateness of the medication, dose, and frequency.1
• Encourage Use of Selected Pharmacies: Direct patients to fill their prescriptions at pharma-
cies that commonly dispense chemotherapy medications, if possible, so that a pharmacist
with knowledge of chemotherapy medications can provide an effective double check of the
physician’s prescription.1
• Provide Patient Education on Safe Handling: When prescriptions are filled, make sure patients
have been given medication fact sheets, gloves, and hazardous waste disposal containers.
150
FOCUS
Oral Chemotherapy Outside the Hospital Setting (continued)
Patients and caregivers should be instructed to wear gloves when handling the medication,
avoid crushing or manipulating the medication (unless instructed by the physician), pour
oral medications over an absorbent mat that can be disposed of in a hazardous waste con-
tainer, and wash their hands after administering the medication.1 (For more information on
handling chemotherapy drugs, see Chapter 8.)
• Educate Parents on Administration: Have parents demonstrate that they know how to
administer the first oral chemotherapy dose before they are allowed to begin administering
the medication to their child in the home.2
• Provide Helpful Tools for Parents: Provide parents with color-coded syringes or syringes with
lines marked as to how much liquid medication should be administered to the child in the
home.2
References
1. Bartel S.B.: Safe practices and financial considerations in using oral chemotherapeutic agents. Am J
Health Syst Pharm 64(9suppl. 5):S8–S14, 2007.
2. Walsh K.E., et al.: Medication errors among adults and children with cancer in the outpatient setting.
J Clin Oncol 27:891–896, Feb. 20, 2009.
151
INDEX
A Androgens and testosterone derivatives, 129

Active labor, 132–133 Anesthesia toxicity, 134
Acute care, 76 Anger, medication safety and, 10–11
Addiction treatment programs, 33 Angiotensin converting enzyme (ACE) inhibi-
Administration safety measures, 147 tors, 128, 129
Adverse drug events (ADEs) Antianxiety medications, 32–33
causes of, 36 Anticoagulation therapy
CPOEs and, 45 best practices for, 114
defined, ix for geriatric patients, 113–114
incidents reporting and, 83 Antihistamines, 126, 132
introduction to, 3 Antihypertensive agents, 114
occurence of, 5 Antineoplastic medications
outpatient visits and, 45 as high-alert medications, 141–142
pediatric patients and, 109 introduction to, 3
prescriptions and, 43 medication errors and, 142
Adverse drug reactions (ADRs) safety processes for, 142–145
defined, ix standards for, 145–146
geriatric patients and, 112–113 Antipsychotic medications
Agency for Healthcare Research and Quality transitions of care and, 77
(AHRQ)
National Quality Forum (NQF) and, 60
long term care patients and, 122–123
Antithyroid drugs, 129 ө
tips for parents to prevent medical errors of “Ask Me 3” education program, 79
children and, 102 At-risk behavior, defined, 16
Aging population, 111–112 Automated dispensing machines (ADMs)7
Alzheimer’s disease, 115, 122 medication management and, 35, 97
Ambulatory care medication errors and, 36, 47, 49, 82, 143
children’s medications in, 140 nurses and, 47, 82
oral chemotherapy in, 150–151 reports from, 84, 95
pediatric patients and, 109
American Academy of Pediatrics, 137 B
American Heart Association, 135 Barbiturates, 132
American Nurses Association Bar code medication administration (BCMA)
“just culture” and, 14 benefits of, 48
medication reconciliation Standards of consequences of, 48–49
Practice and, 72 defined, 47
American Recovery and Reinvestment Act eMARs and, 52
(ARRA), 46 goals of, 47–48
American Society of Clinical Oncology hardware considerations, 50
(ASCO), 145 improvements resulting from, 19–20
American Society of Hospital Pharmacists, use of, 20, 49
147 workarounds, 20–21
Analyzing Performance Problems, 89 BayCare Home Health, 57
153
Beers List, 112, 113 oral, 145, 150–151

Behavioral health care order templates for, 142
nonpharmacological approaches for, 122 safety measures for handling, 146–147
opioids in, 31–34 therapeutic level of, 141, 142
transitions in care and, 76 Children. See Pediatric patients
Beta-adrenergic drugs, 135 Children’s medications, 140
Biological safety cabinet, 147 Chronic disease, 57
Birth defects Chronic pain. See Pain
drugs and, 128 Clinical decision support systems (CDSSs)
teratogenic agents and, 127 basic and advanced, 44
Black box warning, 122 benefits of, 46
Breastfeeding issues, 137–138 CPOEs and, 45
Brigham and Women’s Hospital (BWH) defined, 44
bar code scanning issues at, 48 EHRs and, 45–46
closed loop system at, 42 medication orders and, 44
description of, 35 transitions in care issues and, 77
eMAR training at, 40–41 Clinical Oncological Society of Australia, 36
failure management systems at, 51 Close calls, reporting, 1, 12, 82–83, 95, 104, 144
lessons learned at, 53 Closed-loop medication management system
British National Health Service, 15 at Brigham and Women’s Hospital, 42
Brown Bag Method, 117 at Tan Tock Seng Hospital, 43
work flow for, 43
C Closed-system delivery devices, 147
California Nursing Outcomes Project Codeine, 136
(CalNOC), 24–25 Communication
“Canadian Criteria,” 112–113 about error reporting, 94
Canadian Patient Safety Institute, 36 about information, 23, 69, 71, 76–77
Cancer patients. See Oncology patients about medication safety, 104–106, 136
Carbamazepine, 129 about vision for change, 94
Cardiovascular medications, 114 between nurses and physicians, 48
Carmustine (BCNU), 145 oral and written, 79
Centers for Medicare & Medicaid Services without distraction, 105, 116
(CMS) Community education
30-minute rule from, 49 about medication safety, 68–69
Beers List and, 112, 113 about RHIO, 70
NQF safe practices and, 60 Computerized provider order entry (CPOE)
patient safety and, viii CDSSs and, 45
Change management program, 93–95 chemotherapy and, 143, 150
Chemotherapy drugs. See also High-alert defined, 43
medication administration and Antineo- dose limits and, 104
plastic medications EHRs and, 45–46
CPOE system and, 143, 150 impacts of, 46
double checks for, 89 improvements resulting from, 19–20
error prevention strategies related to, 144 medication orders and, 43, 46
family education about, 144–145 PIS and, 47
interdisciplinary approach for, 36 planning in use of, 20
medication errors involving, 142 purpose of, 43, 45
154
INDEX
Confirmation bias, avoiding, 88–89 Double checks. See Independent double

Continuum of care checks
electronic prescriptions across, 45 Drifting, defined, 16
geriatric patients and, 115, 118 Drug allergies, 46, 97, 105
medication reconciliation across, 60, 63 Drug libraries, 49, 50, 51
Critical access hospitals Drug metabolism, 128, 131
reducing medication errors in, 97–98 Drug references, 44, 46, 67
telepharmacy for, 98–99 Drugs. See Medication(s)
Critical language, using, 8
Critical thinking E
for medication management, 38, 51 Early labor, 132
multitasking issues and, 23 Eight-step change management program,
in technology application, 52 93–95
Culture improvement, 26 Elderly patients. See Geriatric patients
CYP450 enzymes, 131 Electronic health records (EHRs)
advantage of, 70
D CDSSs and CPOE and, 45–46
Daily orders, use of, 150 defined, 45
Debriefings, 26 See also Post-incident drug references from within, 67
debriefing Electronic medication administration records
Decision making (eMARs)
by nurses, 38 BCMA and, 48–49, 52
shared, 63 defined, 48
Dementia-related psychosis, 122 training issues, 40–41
Depression Emergency department
in geriatric patients, 116 high-alert pediatric drugs and, 106
postpartum, 136 medication reconciliation in, 73–74
during pregnancy, 127 telemonitoring and reduction of visits to, 57
respiratory, 133, 134 transitions in care and, 77
Diethylstilbesterol, 129 End-of-life, medications at, 32–33
Discharge instructions Endogenous factors
consumers of discharge information and, defined, 10
71–72 examples of, 10–11
MRPT’s role in, 74 Environmental factors, 10, 12
medication cards and, 116 Epidural analgesia, 133–134
medication information with, 60 Equipment
medication reconciliation during, 62 human factors and, 11
transitions in care and, 76 inspecting, 86, 88
Dispensing errors, 47 for nitrous oxide, 134
Disruptive behavior, 13–14 Erice Medication Errors Research Group
Distractions (EMERGE), 38
communication without, 105, 116 Error reporting
eliminating, 12 communication about, 94
medication errors and, 24–25, 83 encouraging, 8, 104
Dose calculations, 102–103 in just culture, 14–15, 19
Dose limits, 50, 104 Erythromycin, 131
Exogenous factors, 10
155
Extravasation, 146 at Kaiser Permanente, 22–23

Eye and face protection, 147 medication safety and, 28
reviewing breakdowns in, 118
F “Hawthorne effect,” 95
Failure management systems, 51 Hazardous drugs
Failure mode and effects analysis (FMEA), 36 safe handling guidelines, 143, 146–148
Falls Standard MM.01.01.03 for, 143
antihypertensive agents and, 114 Health care
medications as a cause of, 117 aging population impact on, 111–112
Families forcing functions in, 88
interviewing, 87 technology issues in, 20, 45, 46
medication lists creation by, 65, 67 telemonitoring for, 57
medication reconciliation and, 62 unsafe acts in, 9
Family education Health care workers
about chemotherapy drugs, 144–145 hazardous drugs and, 146, 147
about opioids, 32 medication errors and, 82
about safe handling, 148 stress issues, 10
about warfarin, 114 training issues, 15, 17
Fatigue Health information exchange (HIE), 69
medication errors and, 93 Health information technology (HIT)
medication safety and, 10 defined, 39
Fentanyl transdermal patch, 31–32 stimulus for, 46
Fetal heart rate, 126, 133 Health Information Technology for Economic
Finasteride, 129 and Clinical Health (HITECH), 46
Folic acid, 127, 129 Health literacy
Forcing functions, 11, 21, 88 addressing low, 79
defined, 23
G white paper, 22–23
Geriatric patients Heparin infusions, 27
assessing prescriptions for, 112–113 High-alert medication administration. See
conclusion about, 117–118 also Medication errors
depression in, 116 antineoplastic medications, 141–146
frailty and disability and, 115 antipsychotic medications, 122–123
high-alert medications for, 113–114 Beers List and, 112, 113
introduction to, 3, 111 for geriatric patients, 113–114
nursing strategies for, 116–117 minimizing errors in, 8
pharmacokinetic changes in, 113 for obstetric patients, 125
physiological impacts and, 114 opioids, 31–34
sensory impacts and, 115 oral chemotherapy, 150–151
Global Trigger Tool, 25 oxytocin, 135
Gowns and gloves, 147, 151 pediatric patients and, 106
resources, 6
H transitions in care issues and, 77
“halo effect” bias, 89 High-Alert Medication Program (HAMP)
Handoffs development of, 6
communication during, 105 heparin infusions and, 27
improving, 8 implementation of, 6
156
INDEX
introduction to, 2 conducting interviews for, 86–87

measurement for, 7 documentation review for, 86
MedRite program and, 23–25 elements of, 86
methodology, 7 post-incident debriefings and, 85
objectives of, 7 Incident reporting
observational audits, 25 compliance issues, 95
success of, 27–28 electronic, 85
High-efficiency particulate air (HEPA) filter, by nurses, 1
147 as a patient safety tool, 83
Home care review of, 82–83
consumers of discharge information and, Independent double checks
71 defined, 21
opioids in, 31–34 factors in, 21–22
oral chemotherapy in, 150–151 pediatric patients and, 104
telemonitoring in, 57–58 using, 8, 88–89
Home care aides, 79 Induction of labor, 135
Hospice care Infants. See Pediatric patients
opioids in, 31–34 Inhalation anesthetics, 134–135
telemonitoring in, 57 In-room SBAR, 22
transitions in care and, 76 Institute for Healthcare Improvement (IHI)
Hospital admissions. See also Discharge ADE project, 63
instructions Global Trigger Tool by, 25
medication list at time of, 60, 62, 116 medication reconciliation and, 62, 72
medication reconciliation during, 61, 69 Plan-Do-Study-Act methodology and 72
MRPT’s role in, 74 Institute for Safe Medication Practices (ISMP)
telemonitoring for preventing, 57, 58 double checks and, 89
transitions in care and, 76 high-alert medications and, 6, 31, 125, 135
Human error, defined, 16 medication administration and, 49
Human factors Institute of Medicine (IOM).
defined, 9 national center for patient safety and, 52
education about, 15, 18–19 definition of system and, 16
engineering (HFE), ix, 9, 51 reports, viii–ix, 5, 38, 59
interventions and measurement/analysis Interdisciplinary teams
of, 26–27 challenges related to, 36–37
medication safety and, 9–13, 23 need for, 36
risk management and, 82 nurses as key members of, 39
surveillance of, 48 structure of, 39
in task analysis, 11 Interviews
technology and, 20, 37, 51, 53 conducting, 86–87
Hydrocodone, 137 elements of, 87
Intracavitary routes, 145
I Intrapartum pain relief, 125, 132
Ibuprofen, 137 Intraperitoneal administration, 145
Inappropriate Prescribing in the Elderly Tool Intravenous (IV) potassium chloride and
(IPET), 112–113 insulin, 141
Incident investigation Intravenous therapy, 36–37, 77, 132, 145
by category, 85 Investigation
157
incident reporting and, 85–86 Kids Aren’t Just Small Adults: Medicines,
risk analysis and, 84–85 Children, and the Care Every Child
Deserves brochure, 109
J Kotter, John, 93
Joint Commission
health literacy white paper by, 22–23 L
National Patient Safety Goals, 43, 60, 105, Labeling
117, 141 for LASA drugs, 12, 87
Sentinel Event Alert 35, 60 for medication containers, 117
Sentinel Event Alert 39, 104 for medication storage, 87
Sentinel Event Alert 40, 13 for pediatric drugs, 103
Sentinel Event Alert 42, 20 Labor and delivery
Standard MM.01.01.03, 143 induction of labor and, 135
Standard MM.01.02.01, 87, 144 pain relief during, 132–135
Standard MM.04.01.01, 104 preeclampsia and, 136
Standard MM.05.01.09, 117 preterm labor and, 135
Standard MM.06.01.03, 33–34 Lactation drugs, 137
Standard MM.07.01.03, 86 Language barriers, 79, 90, 92
Standard PC.01.02.07, 115 Leaders
Standard PC.04.01.05, 62 medication reconciliation issues and, 72
Standard PC.04.02.01, 60 risk-reduction strategies and, 93–95
Joint Commission International’s (JCI) safety culture and, 13, 103
Patient Safety Goals, 43, 141 Lithium, 130
Standard MMU.7.1, 86 Local anesthesia, 133–134
Just culture Long-term care
advisory board, 15 antipsychotic medications in, 122–123
algorithm, 14–17 Beers List and, 112, 113
defined, 14, 16 medication technicians in, 120–121
importance of, 28 oral chemotherapy in, 150–151
incidents reporting and, 83 transitions in care and, 76, 77
policy and, 14, 16–17 Look-alike/sound-alike (LASA) drugs
ADMs and, 47
K antineoplastic medications, 143–144
Kaiser Permanente Northern California labeling for, 12, 87
(KPNC) medication errors and, 36, 144
CPOE and BCMA at, 19–20 storage issues, 36, 87
double checks at, 21–22
HAMP program at, 6–7 M
improvement at, 26–27 Magnesium sulphate, 135
MedRite program at, 23–25, 27 Management report, 21
next steps at, 27–28 Managing Error in a Just Culture, 16–17
Patient Safety University (PSU) at, 15, Marx, David, 15
17–19 Massachusetts Coalition for the Prevention of
Responsible Reporting Form, 15 Medical Errors, 60
safety culture at, 13–15 Massachusetts Institute of Technology, 47
Medication administration process
aim of automating, 39
158
INDEX
closed loop, 42 risks for, 120

complexity of, 37 smart infusion pumps and, 36
drug allergies and, 46, 97, 105 staff members and, 90
EHRs and, 46 technology and, 36, 97–99, 104
human factors in, 11 during transitions in care, 77
MedRite program for, 23 unsafe acts and, 6–7
multitasking issues and, 23–24 workarounds and, 84
observation of, 84 Medication information
by parents, 151 addressing lack of, 37–38
policies and procedures for, 103, 104 communication of, 23, 69, 71, 76–77
safeguarding safety zone of, 24–25 with discharge instructions, 60
safe practices for, 38 Medication lists
sensory impacts and, 115 creating and updating, 65, 67, 116
technology for, 47 medication cards and, 65
timeliness of, 48–49 medication reconciliation and, 65–69,
Medication Administration System - Nurses 71–72
Assessment of Satisfaction (MAS-NAS), at time of hospital admissions, 60, 62, 116
52 using technology for, 70
Medication Appropriateness Index (MAI), 113 Medication management
Medication cards breastfeeding issues and, 137–138
access to, 65 challenges related to, 37–38
design issues, 65 closed loop, 42–43
discharge instructions and, 116 critical thinking for, 38
medication list and, 116 decision making in, 38
sample, 66 evolution in, 35
Medication errors geriatric patients and, 115
antineoplastic medications and, 142 need for safer, viii
causes of, ix–x physiological impacts and, 114
chemotherapy drugs and, 142 safety rounds and, 41
conclusion about, 95–96 technology for, 42–51
cost issues, viii testing the process of, 40
defined, ix Medication orders
distractions and, 24–25, 83 CDSSs and, 44
fatigue and, 93 CPOEs and, 43, 46
flawed assumptions and, 81 evaluation of, 97
human errors and, 82 medication reconciliation and, 60, 61
introduction to, 2, 81 for pediatric patients, 103, 104
LASA drugs and, 36, 144 PIS and, 47
in pediatric patients, 101–106, 109 telepharmacy for, 98
policy violation issues, 86 transmission of, 49
potential sources of, 84 Medication overrides, 21, 47
prescription assessment tools and, 113 Medication reconciliation
preventing and reducing, x, 77 accountability for, 72–73
probability of, ix on admission form, 70
risk analysis and, 84–88 Brown Bag Method for, 117
risk identification and, 82–84 conclusion about, 74
risk reduction for, 88–95 design and implementation checklist, 73
159
during discharge instructions, 62 policies and procedures for, 40

electronic, 45 risk management and, 82
in emergency department, 73–74 unsafe acts and, 9
goals and standards for, 60–61 Medication storage
introduction to, 2, 59–60 inspecting, 87
at Lourdes Hospital, 62–64 labeling for, 87
medication lists and, 65–69, 71–72 LASA drugs and, 36, 87
medication orders and, 60, 61 obtaining medications from, 97
MRPT position for, 74 Medication technicians, 120–121
process of, 61–62 MedRite program, 23–25, 27
slogan for, 67–68 Milk/plasma ratio, 136–137
struggles with, 62 Milligram-per-kilogram dose, 102
during transitions in care, 62 Misoprostol, 130
Medication Reconciliation Pharmacy Techni- Model State Pharmacy Act, 98
cian (MRPT), 74 Mood disorders, 136
Medication(s) Morphine sulphate, 132
as a cause of falls, 117
children, 140 N
discrepancies, 76, 77 National Association of Boards of Pharmacy,
emerging information about, 134 98
at end-of-life, 32–33 National Hospice and Palliative Care Organi-
lack of knowledge about, 37–38 zation, 33
for mood disorders, 136 National Institute for Occupational Safety and
pain and, 115 Health (NIOSH), 31, 143
patient education about, 109, 117, 140 National Patient Safety Agency, 15
during pregnancy, 127–132 National Patient Safety Goals (NPSGs)
safe disposal of, 32 anticoagulation therapy, 114
Medication safety. See also Technology communication among caregivers, 105
ADEs and, 5 high-alert medications, 141
anger and, 10–11 medication list, 65
for cancer patients, 141–148 medication reconciliation, 60
communication about, 104–106, 136 medication safety, 43, 141
community education about, 68–69 patient harm from falls, 117
conclusion about, 27–28 National Quality Forum (NQF), 60
disruptive behavior and, 13–14 National University Hospital, 42, 43
double checks and, 21–22 Newborn. See Pediatric patients
engaging patient in, 22–23 NICHE concepts, 118
error reporting and, 14–15 Nitrogen mustard, 146
failure management systems for, 51 Nitrous oxide, 134
fatigue and, 10 Nonsteroidal anti-inflammatory drugs
for geriatric patients, 111–118, 120–123 (NSAIDs), 130, 135
handoffs and, 28 Nurse knowledge exchange (NKE)
human factors and, 9–13 defined, 22
introduction to, 2 health literacy and, 22–23
measurement of, 25–26 in-room safety check, 22
for obstetric patients, 125–137 in-room SBAR, 22
for pediatric patients, 101–106, 109 Nurse leaders
160
INDEX
incidents reports and, 83, 96 Ongoing Professional Practice Evaluation

post-incident debriefings and, 85–86 reporting process, 13
risk-reduction strategies for, 89–90, 93–95 Opiates/Opioids
work process observation by, 84 addiction treatment programs, 33–34
Nurse(s). See also Medication errors; family education about, 32
Technology fentanyl transdermal patch, 31
ADMs and, 47 in home care and hospice, 31
challenges for, 37–38, 125 during labor, 133
communication issues, 48, 79 management of, 31–32
decision making by, 38 Oral and topical routes, 145
double checks by, 89 Oral chemotherapy, 145, 150–151
improvements and work issues for, 26–27 Order templates, 142
incidents reports by, 1 Organizational factors, 103
as key members of interdisciplinary team, Our Lady of Lourdes Memorial Hospital
39 ADE team at, 63
medication administration by, 11 care delivery system at, 64
multitasking issues, 23–24 community education by, 68–69
opioids and, 31–34 medication lists at, 65–69, 71–72
role of, 1–2 medication reconciliation at, 59–60, 62–64,
safety culture and, 13–14 74
super-user role of, 40–41 professional practice model at, 64
as transformational leaders, 63 program slogan by, 67–68
Nurses Improving Care for Health System Outpatient visit
Elders (NICHE), 118 ADEs and, 45
Nursing homes medication reconciliation and, 62
antipsychotic medications in, 122–123 opioids and, 33
transitions in care issues and, 77 transitions in care and, 77
Nursing practice/strategies Override tracking system, 21
for geriatric patients, 116–117 Oxygen as a drug, 135
key implications for, 103 Oxytocin
Nursing work flow, 37 for inducing labor, 135
managing use of, 125
O safety issues, 126
Obstetric drugs, familiarity with, 125
Obstetric patients P
introduction to, 125 Pain
during labor, 132–136 in geriatric patients, 115
perinatal safety for, 126 labor, 132
postpartum period of, 136–137 medications and, 115
prenatal period of, 127–-132 opioids for, 32
Older adults. See Geriatric patients Pain relief
Oncology Nursing Society (ONS), 145 for breastfeeding women, 137
Oncology patients induction of labor and, 135
antineoplastic medications for, 141–146 intrapartum, 125, 132
conclusion about, 148 preeclampsia and, 136
treatment goals for, 141 preterm birth and, 135
Ongoing education, 8 regional analgesia, 133–135
161
systemic analgesics, 132–133 Personal digital assistants (PDAs), 47, 53

transdermal route of, 31 Personal protective equipment (PPE), 146,
Parents 147
medication administration by, 151 Pharmacodynamics, defined, 113
pediatric medical errors and, 101, 102 Pharmacokinetics, defined, 113
Patient education Pharmacy information system (PIS), 47, 98
about chemotherapy drugs, 144–145 Phenytoin, 130
about medications, 109, 117, 140 Physical and psychosocial evaluation, 116
about opioids, 31–32 Physical space, assessing, 8
about safe handling of drugs, 148, Physicians
150–151 communication issues, 48
about warfarin, 114 interdisciplinary teams and, 36
Patient(s) pediatric patients and, 102, 104
communicating information to, 23 safety culture and, 13, 26
falls and, 114, 117 Physiological impacts, 114
health literacy issues, 79 Plan-Do-Study-Act methodology, 72
interviewing, 87 Point-of-care systems
medication lists creation by, 65, 67 at Brigham and Women’s Hospital, 42
medication reconciliation and, 62 medication errors and, 36–37
medication safety and, 22–23 Policies and procedures
Patient safety development of, 73
CDSSs for, 45 for medication administration, 103, 104
CMS and, viii for medication safety, 40
commitment to, 39 for opioid medications, 33
evolution in, 35 for safety culture, 13
incidents reporting as a tool for, 83 staff education about, 8
WHO’s solutions for, 61 Polypharmacy, 131
Patient Safety University (PSU), 15, 17–19, 27 Post-incident debriefings, 85
Pediatric patients Postpartum period
ambulatory care and, 109 breastfeeding issues, 137–138
dose calculations for, 102–103 depression in, 136
giving medication to, 104, 105 drugs used during, 136–137
high-alert medications related to, 106 mood disorders in, 136
improving medication safety for, 103–106 Preeclampsia, 136
introduction to, 2–3 Pregnancy. See also Labor and delivery;
medication errors and, 101–102 Postpartum period
Penicillin, 131 depression during, 127
Performance analysis drug formulary categories for, 127–128
flowchart, 91–92 drug interactions during, 131–132
tools, 89 drug metabolism during, 128, 131
Performance feedback, 95 medications during, 127–132
Performance improvement, 23–25 SSRIs during, 127
Perinatal arena, challenges for nurses in, 125 Prenatal period
Perinatal drugs, 125 birth defects and, 128
Perinatal safety, 126 medication during, 127
Perineal sprays, 136 Prescriptions
Peripheral administration, 145 ADEs and, 43
162
INDEX
Brown Bag Method and, 117 leaders and, 13, 103

electronic, 45 support for nurses, 13–14
for geriatric patients, 112–113 Safety rounds, 41, 83
technology for, 35, 150 SBAR technique
transcription errors and, 43 description of, 8
Preterm birth, 135 medication safety and, 27, 28
Preventing Medication Errors, 5, 38 in-room, 22
Procedural violations, 6 Selective serotonin reuptake inhibitors
Psychological safety (SSRIs)
fostering, 12 birth defects and, 128
at Kaiser Permanente, 13 breastfeeding issues and, 137
during pregnancy, 127
R Sensory impacts, 115
Reason, James, ix, 15 Sentinel event, defined, 126
Reckless behavior, 6, 7, 16 Sentinel Event Alert 35, 60
Regional analgesia Sentinel Event Alert 39, 104
epidural, 133–134 Sentinel Event Alert 40, 13
inhalation anesthetics, 134–135 Sentinel Event Alert 42, 20
Regional health information exchanges Short-term wins, 94
(RHIO) Sleep deprivation, 10
community education for, 70 Smart infusion pumps
purpose of, 69 dosing limits, 50
Remote pharmacies, 98 drug libraries and, 50
Respiratory depression, 133, 134 effective use of, 49
Responsible reporting, encouraging, 8 medication errors and, 36
Risk analysis purpose of, 49
investigation and, 84–85 risks related to, 50–51
post-incident debriefings and, 85–86 via wireless networks, 50
Risk identification/management Speak UpTM brochure, 109
defined, 82 Spill kits, 147
incidents reporting and, 82–83 Staff education
work environment and, 83–84 about chemotherapy drugs, 144
Risk reduction strategies about nonpharmacological approaches,
implementation of, 93–95 123
monitoring of, 95 about policies and procedures, 8
selecting, 88–90, 92 about technology implementation, 41
Root cause analysis, 83, 84, 90 Staff members
Royal College of Physicians and Surgeons of medication errors and, 90
Canada, 36 screening, 90, 92–93
Rural hospitals Staff nurses
reducing medication errors in, 97–98 eMAR training and, 40–41
telepharmacy for, 98–99 as practice consultants, 39–40
support for, 41
S Standard MM.01.01.03, 143
Safety culture Standard MM.01.02.01, 87, 144
creating, 13 Standard MM.05.01.09, 117
error reporting and, 14–15 Standard MM.06.01.03, 33–34
163
Standard MM.07.01.03, 86 purpose of, 98

Standard MMU.7.1, 86 Templates, 142
Standard PC.01.02.07, 115 Teratogenic agents
Standard PC.04.01.05, 62 birth defects and, 127
Standard PC.04.02.01, 60 commonly known, 129–131
Streptomycin and kanamycin, 130 defined, 128
Stress, 10 Tetracycline, 130
“Subject Matter Experts” (SMEs), 72 Thalidomide, 128, 130
Substandard performance, 89–90 Tocolytics for preterm labor, 135
Substitution test, 16 To Err is Human, viii, 59
System, defined, 16 Training issues
Systemic analgesics, 132–133 health care workers, 15, 17
technology implementation, 40–41
T Transitions in care
Tan Tock Seng Hospital, 42, 43 acute care and, 76
Task analysis, 11 behavioral health care and, 76
Teach back method, 79 communication during, 105
Technology long term care and, 76
acronyms, 37 medication errors at, 45, 77
to address lack of medication information, medication reconciliation at, 62
37–38 Trigger Tool methodology, 25
advancements in, 52–54 Trimethadione and paramethadione, 130
chemotherapeutic drugs and, 143
education plans, 40–41 U
end-user feedback for, 41 Universal Protocol for time-out, 8
executive sponsorship for, 39–40 Unsafe acts
implementation of, 53 causes of, 9
introduction to, 2 defined, 7
for medication administration, 47 elimination strategies and, 11–12
medication errors and, 36, 97–99, 104 focusing on origin of errors and, 9
for medication lists, 70 medication errors and, 6–7
for medication management, 37–38, responses to, 7
42–51 Unusual events, 25–26
nurse involvement in choosing, 38–41 Usability testing
role of, 19–21 defined, 12
satisfaction with, 51–52 human factors and, 12–13
telemedicine, 57–58 U. S. Food and Drug Administration (FDA),
use of, 28 31, 50, 122
workarounds, 48
Telemonitoring V
cost savings with, 58 Valproic acid, 130
in home care, 57 Vesicant antineoplastic agents, 146
preventing hospitalizations with, 57–58 Veterans Health Administration, 48, 57
Telepharmacy Violation-producing conditions, 9–10
in critical access and rural hospitals, Violations, defined, 16
98–99 Vitamin A and derivatives, 131
models for, 98–99 Vitamin K
164
INDEX
injection for newborns, 137 Work environment

warfarin and, 114, 128 evaluation of, 87
observation of, 84
W risk identification and, 83
“walking epidural,” 133, 134 Work process
Warfarin evaluation of, 87
patient education about, 114 observation of, 84
during pregnancy, 129 World Alliance for Patient Safety, 61
Williams, Jeremy, 10 World Health Organization (WHO), 61, 140
Workarounds
identifying, 20–21
medication errors and, 84
technology, 48
165

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What are some of the services provided by Joint Commission Resources and Joint Commission International?

What are some of the services provided by Joint Commission Resources and Joint Commission International?

What is the focus of the book 'The Nurse's Role in Medication Safety'?

What is the focus of the book 'The Nurse's Role in Medication Safety'?

The Nurse’s Role in Medication Safety, Second Edition

The Nurse’s Role in Medication Safety, Second Edition

About Joint Commission Resources

Please visit our Web site at www.jointcommissioninternational.org.

Joint Commission Resources Mission

© 2012 Joint Commission Resources, Inc., Compl.

Printed in the U.S.A. 5 4 3 2 1

Chapter 1. Medication Safety: Reducing Error Through Improvement Programs 5

FOCUS: High-Alert Medications: Opioids in Home Care, Hospice, and

Chapter 2. Medication Safety: Using Technology 35

FOCUS: Technology: Benefits of Telemonitoring in Home Care 57

Chapter 3. Medication Reconciliation: Lessons Learned 59

FOCUS: Transitions in Care: Communication of Medication Information

FOCUS: Patient Education: Addressing Low Health Literacy Among

Chapter 4. Medication Errors: Risk Management 81

FOCUS: Technology: Using Telepharmacy and PIS to Reduce Risks for

Chapter 5. Medication Safety: Considerations for Pediatrics 101

FOCUS: Patient Education: Educating Parents About Their Children’s Medications

Chapter 6. Medication Safety: Considerations for Geriatrics 111

FOCUS: Staff Education: Medication Technicians in Long Term Care 120

FOCUS: High-Alert Medications: Antipsychotic Medications in

Chapter 7. Medication Safety: Considerations for Obstetrics 125

FOCUS: Patient Education: Educating Parents About Infant Formula

Chapter 8. Medication Safety: Considerations for Oncology 141

FOCUS: High-Alert Medications: Oral Chemotherapy Outside the

The Issue of Errors additional costs connected with the treatment

• Poor communication, such as incomplete medication regimens. The responsibility carried

• Medication safety issues in selected clinical Chapter 3. Medication Reconciliation:

Chapter 7. Medication Safety: Terms Used in This Book

© 2012 Kaiser Permanente, Chapter 1 5

Responses to Unsafe Acts

SIDEBAR 1-1. Kaiser Permanete Nothern California High-Alert Medication Program

HAMP Objectives the limited list of high-alert medications, processes,

FIGURE 1-1. Tools and Strategies for Minimizing Errors in High-Alert

• Standardize Protocols: This is vital for administering high-alert drugs.

Source: Kaiser Permanente. Used with permission.

Defined: Human Factors and

conditions” that influence a person’s likelihood ◦ Environmental factors such as noise,

Establishing a just culture advisory board. Patient Safety Education/Training

FIGURE 1-2. Managing Error in a Just Culture—An Algorithm for Promoting a

1.0 Policy Statement

FIGURE 1-2. Managing Error in a Just Culture—An Algorithm for Promoting a

Source: Kaiser Permanente. Used with permission.

PSU2 begins with an introduction to safety The Role of Technology in a

FIGURE 1-3. Patient Safety University—Phase 1: Agenda

Patient Safety University

Date/ Time Topic

Source: Kaiser Permanente. Used with permission.

FIGURE 1-4. Patient Safety University—Phase 2: Course Content

Phase 2: Course Content

Patient Safety University

Module Time Frame

Source: Kaiser Permanente. Used with permission.

management report to capture override data Independent Double Checks

Other factors to be included in the decision- Nurse Knowledge Exchange