Medication Errors

Lab Group B

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

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

Medication errors are prevalent in Quick Facts:

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

Discuss: Our groups analysis of the method of dual verification

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

Focus: Benefits and disadvantages of two nurse double checking

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

Does dual verification decrease the occurrence of high

alert medication errors in high acuity patients in

comparison to not using dual verification?

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

Local
Selective High Alert Medications

Hospital based

Administration

Patient Verification

6 Rights

Independent double check

Current Practice

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

National
New Zealand

Canada

United States

Malaysia

Taiwan

England

Australia

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

3 studies indicated limitations with double checks

2 studies suggest unclear guidelines of double
checking
2 studies state training and a dedicated work
environment are required
1 study discusses lack of knowledge and disruptive
environment made double checking difficult
https://drive.google.com/file/d/0B89GnNkLZMJnWmpKUEJqeUZERjg/view
Strengths of All Studies
Reducing the risk of harm from intravenous potassium
Identified a poor system for potassium administration
Length of 2 years to gather data for study

Comparison of medication safety systems in critical access hospitals

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

Paediatric nurses understanding of the process and procedure of double

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

Double checking: A second look

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

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

Randomized and controlled

Medication double-checking procedure in clinical practice: Oncology nurses

experiences
Cross sectional study done in three different hospitals

First investigation into double-checking procedures in cancer care

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

Nurses Knowledge about double-checking process for med administration

Looked at the opinions of the nurses giving medications

Looked at various units for pediatrics to medical-surgical.

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

May need longer duration of study to gather cultural effects

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

Comparison of medication safety systems in critical access hospitals

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

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

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

Hawthorne effect

Paediatric nurses understanding of the process and procedure of double

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

Only 6-7 nurses were used in homogenous groups

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

Does an Insulin Double Checking Procedure Improve Patient Safety?

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

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

Medication double-checking procedure in clinical practice: Oncology nurses

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

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

Nurses Knowledge about double-checking process for med administratio

Conducted in one hospital, so it can not be generalizable

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

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

Findings and Conclusions

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

Designated distraction-free zones

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

Paperless charting for double-checks

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

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

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

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

system launch

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

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

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

Cost Analysis
Monetary Cost:

Component of the average nursing salary in a 12-hour

shift:

Bureau of Labor Statistics Average Hourly Wage for

RNs:

$34.14/hour

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

within a 12-hour shift

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

also take into account cost of overtime/time and a half

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

Time to double check

Time for extra training and education on high-

alert medications

Availability of Nursing Staff (a registered nurse

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

Cost nationwide of medication

errors (16.4 billion annual costs)

Costs of individual hospital

lawsuits

1. Springfield hospital sued for

over $100,000

2. University of Maryland Medical

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

Risk:

Inconsistent
expectation for what
constitutes a double
check

Double checking takes

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

Heavy workload & quiet

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

Benefit:

Manual double checks decrease

med errors by 10%

In one study, independent

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

When used in conjunction with other forms of double checking,

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

One study reduced 33 annual med error events in 12 months to

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

Our PICOT goal:

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

Is it: a Specific Measurable Attainable Realistic Timely outcome?

Is it: an evaluation based off of the recommendations and

supported by our research?

Implement Checks
Computerized Checks
Environment
Education
1. Medication double checks were successfully
implemented resulting in a reduction of the number
of medication errors that resulted in harm by 90%
in the first year of implementation.
2. Mandatory computerized double checks were
successfully integrated into medication
administration resulting in an increase of
compliance using hospital specific double checking
policy for each incidence of administration of high
acuity medication.
3. Medication preparation for administration was
conducted in specially allocated medication rooms
to maintain an environment that is safe, quiet,
private and organized resulting in a reduction of
medication errors immediately upon designation of
this environment.
4. Medication Double checking was successfully
defined and standardized in facility wide education
or training session causing an increase in
compliance and correct use of policy and a
reduction of medication errors upon completion of
all required education or training.
In summary..

...So does dual verification

decrease the occurrence of high
alert medication errors in high
acuity patients in comparison to
not using dual verification????
 Research Summary
Medication errors are a significant issue, and Ultimately double checking
is well supported and current practice does verify high acuity
medications.
Data from 6 of the 9 articles fully supports efficacy of double checks.
Limitations in the other 3 were guideline/implementation confusion, not
contradicting use of double checks
Strong studies w/ large studies with large samples, variables take into
consideration, like age and gender, varied units, varied facilities, detail
and unanimously supported either the implementation or further
research
Weak data: time issues, no emergency admin/ error data, not exhaustive
errors, bias, Hawthorn effect.
Monetarily, it is realistic and cost effective compared to error cost
The benefits outweigh the risk, it just difficult to manage time, and ensure
consistent implementation
Studies
1. Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses
experiences

2. Does an Insulin Double-Checking Procedure Improve Patient Safety

3. Double checking: a second look

4. Reduction of medication errors in a pediatric cardiothoracic intensive care unit

5. Nurses' knowledge about the double-checking process for medicines administration**

6. Comparison of medication safety systems in critical access hospitals: Combined analysis of two studies

7. Pediatric nurses' understanding of the process and procedure of double-checking medications

8. Medication Errors in Labor and Delivery: Reducing Maternal and Fetal Harm

9. Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the hematology
setting
References
Alsulami, Z., Choonara, I., & Conroy, S. (2014). Nurses' knowledge about the double-checking process for medicines
administration. Nursing Children and Young People, 26(9), 21-26. doi:10.7748/ncyp.26.9.21.e378

Barras, M., Moore, D., Sweedman, M., Wilkinson, C., Taylor, K., Morton, J. (2013). Reducing the risk of harm from intravenous
potassium: a multi-factorial approach in the haematology setting. Journal of oncology pharmacy practice, 20. Doi:
10.1177/1078155213504443

Bureau of Labor Statistics. (2016, March 30). Occupational Employment Statistics. Retrieved from
https://www.bls.gov/oes/current/oes291141.htm

Cochran, G. L., Barrett, R. S., & Horn, S. D. (2016). Comparison of medication safety systems in critical access hospitals:
Combined analysis of two studies. American Journal of Health-System Pharmacy, 73(15), 1167-1173. doi:10.2146/ajhp150760

Cousins, S. (2017, March 29). Phone interview. [Canyon Vista Medical Center]

DeAngelis, T. (2016, September). Preventing medical errors: Psychologists are revamping health-care systems to keep patients
safe from life-threatening mistakes. Retrieved from http://www.apa.org/monitor/2016/09/preventing-errors.aspx

Dickinson, A., James, N., McCall, E., Twomey, B. (2010). Pediatric nurses' understanding of the process and procedure of
double-checking medications. Journal of Clinical Nursing, 19(5-6), 728-735. doi:10.1111/j.1365-2702.2009.03130.x
Hewitt, T., Chreim, S., & Forster, A. (2015). Double checking: a second look. Journal of Evaluation in Clinical Practice,22(2), 267-
274. doi:10.1111/jep.12468

Hughes, R.G., Blegen, M.A. (2008). Patient safety and quality: An evidenced-based handbook for nurses. Rockville: Agency for
Healthcare Research and Quality U.S. Department of Health and Human Services.

Institute for Safe Medication Practices. (2013, June 13). Independent double-checks: Undervalued and misused: Selective use of
this strategy can play an important role in medication safety. Retrieved from
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=51

Johns Hopkins Medicine. (2016, May 3). Study suggests medical errors now third leading cause of death in the u.s. Retrieved from
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_
us

Keiffer, S., Marcum, G., Harrison, S., Teske, D. W., Simsic, J. M. (2015). Reduction of Medication Errors in a Pediatric
Cardiothoracic Intensive Care Unit. Journal of Nursing Care Quality., 30(3), doi: 10.1097/NCQ.0000000000000098

Kissinger, B. (2016). Does an insulin double-checking procedure improve patient safety? The Journal of Nursing Administration,
46(3), 154-160. doi:10.1097/NNA.0000000000000314
Holleran, K. (2013, November 5). Springfield hospital and doctor accused of malpractice sued in st. clair county. Retrieved from
http://madisonrecord.com/stories/510576589-springfield-hospital-and-doctor-accused-of-malpractice-sued-in-st-clair-county

McDaniels, A.K. (2016, September 22). UMMS must pay family $10 million in malpractice suit. Retrieved from
http://www.baltimoresun.com/health/blog/bs-hs-umms-malpractice-verdict-20160922-story.html

Meyer, A. (2017, March 29). Personal interview. [St. Joseph Hospital]

Modic, M.B., Albert, N.M., Sun, Z., Bena, J.F., Yager, C., Cary, T., Corniello, A., Kaser, N., Simon, J., Skowronsky, C.,

National Priorities Partnership. (2010, December). Preventing medication errors: A $21 billion opportunity. Retrieved from
file:///C:/Users/Grace/Downloads/NPP_Medication_Error.pdf

Pa Patient Saf Advis (2009). Medication Errors in Labor and Delivery: Reducing Maternal and Fetal Harm. (n.d.). Retrieved from
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/01.aspx

Rodriguez, J. (2017, March 29). Phone interview. [Phoenix Childrens Hospital]

Schwappach, D. L., Pfeiffer, Y., & Taxis, K. (2016). Medication double-checking procedures in clinical practice: a cross-sectional
survey of oncology nurses' experiences. BMJ Open, 6(6). doi:10.1136/bmjopen-2016-011394

Secker, D. (2017, March 29). Phone interview. [Dignity Health Mercy Gilbert Hospital]

Yodice, J. (2017, March 29). Phone interview. [Tucson Medical Center Hospital]