Adverse Trend And Data Management: Medication Error Reporting System

Adverse Trend & Data Management
Carrie Minton
HCS/482
March 16, 2015
Eric Rios

Adverse Trend & Data Management An adverse trend in the health care system is a serious event causing harm to patients as a result of inadequate medical care. A trend is a consistent and pressing issue that needs to be addressed. Trending adverse events indicate that the care given is resulting in an undesirable patient outcome. An important adverse trend that is addressed in this paper is medication errors. MEDMARX is a nationally recognized, web-based, anonymous, and voluntary medication error reporting system (Rashidee, Hart, Chen, & Kumar, 2009). Healthcare facilities use this reporting system to report medication error data. Within a three
year time period, 443,683 medication errors were reported from 537 facilities of which 98% reported from an inpatient setting (Rashidee, Hart, Chen, & Kumar, 2009). The highest reported instances take place during the administering and dispensing phases (29% each) followed by transcribing and documentation phases at 25% (Rashidee, Hart, Chen, & Kumar, 2009). Pharmacotherapy remains the primary mode of treatment for patients, therefore increasing the need to further enhance medication administration safety processes. According to the Center for Disease Control and Prevention, adverse drug events cost 3.5 million dollars in extra medical costs each year and almost half of the costs are preventable (2012). Patient safety is the focus in nursing and because medication administration is a large part of caring for patients, errors need to be managed. Data collection is very important when it comes to medication errors.
Any kind of error, whether it causes no harm to the patient or kills the patient, is still an error that needs to be reported and addressed. This collection of data begins with looking at the CPOE (electronic physician orders), Pyxis dispense history, eMAR, narcotic waste history (if a narcotic error), barcode scans, and the stage that the error occurred. These are all important data pieces to collect and analyze in order to pain the picture of what happened and why. The stages of where/when the error occurred are very important for identifying patient harm. Stage one is considered a prescribing error where the incorrect drug or dose is selected for a patient. This kind of error is also the cause of illegible handwriting and/or the misspelling of a drug with a similar name (Williams, 2007). Prescription errors make up for between 1-11% of all written prescriptions (Sanders & Esmail, 2003). Stage two is where dispensing errors occur. This is considered to be selection of the wrong product where usually there are look alike and sound alike drugs involved such as Losec and Lasix. Step three and four are the preparation and administering stages and the rates of these errors vary between 3.5% and 49% (NPSA, 2007). These stages are areas of high risk within nursing practice where nurses fail to verify important information such as drug, patient, dose, time, and route (Williams, 2007). IV drugs are suggested to be as high as 25% of medication errors in these stages (Bruce & Wong, 2001). Stage five is errors in monitoring outcome. Patients take certain drugs that require continuous monitoring to ensure the dosing is correct and there are no adverse
reactions. When reviewing the collected data, it is helpful to look at the six rights and categorize the medication error. The six rights include right patient, right drug, right dose, right route, right time, and right outcome. Many drug errors result in the nurse’s lack of observing one of these rights. Categorizing the severity of the medication error is also important for later on reporting the med error. The categories include A (no error, potential error), B (actual error, did not reach patient), C (actual error, caused no harm), D (additional monitoring required, caused no harm), E (treatment/intervention required, caused temporary harm), F (initial/prolonged hospitalization, caused temporary harm), G (caused permanent harm), H (near death event), I (death). It is important to review the data and determine where the medication error falls because depending upon the category; the result of disciplinary action will vary. After collecting all of the data and reviewing the data, an incident report or QCC needs to be filed. The report includes the date of the incident, medication error description, type of drug/s, who, what, when, why, where, how, rights of the patient violated, category of medication error, and all other data collected. This information then determines the outcome and disciplinary action or education/training needed for those who are involved. Technology used in this process includes anything from data collection (Pyxis, CPOE, MAR, EHR, EMR, etc…) to the filing an incident report anonymously. In today’s healthcare, technology is used in everything from the time the patient is admitted to the time they leave. Medication errors occur regardless of technology and sometimes because of technology. Using the technology systems in place efficiently can help to provide safer patient care. When a medication error occurs, it is important to keep patient and staff information confidential. When not involved in a medication error it is still ethically important to anonymously report what happened; not because you want to get someone in trouble, but so that you can help be a part of improving medication administration safety. When a error occurs it is also important to only collect pertinent data to the case and not go snooping around where it is not needed. HIPPA is to be taken seriously especially during collecting, swapping, and merging data from different technology sources. We are to protect the confidentiality and security of the healthcare system by establishing and enforcing standards of electronic data. Training and education is provided annually for staff in order to be more aware of possible threats in a breach of HIPPA. The reporting of medication errors is not there for punitive reasons; it is all in the name of improving patient safety and outcomes.

See Appendix B for flowchart.
References
Bruce, J., & Wong, I. (2001). Parenteral drug administration errors by nursing staff on an acute medical admissions ward during day duty. Drug Safety, 24(11), 855–62.
Sanders, J., & Esmail, A. (2003). The frequency and nature of medical error in primary care: understanding the diversity across studies. Family Practice, 20, 231–6.
Williams, D. P. (2007). Medication errors. Journal of the Royal College of Physicians Edinburgh, 37, 343–6.
Centers for Disease Control and Prevention. (2012). Medication safety basics. Retrieved March 16, 2015 from http://www.cdc.gov/medicationsafety/basics.html#ref