MNA Position Statement on Medication Errors

Statement of the Problem

The Institute of Medicine (IOM, 1999) aptly titled their report, “To Err Is Human,” as the enormity of the medical error problem was revealed to the nation. Human beings, even the most diligent, make errors. The traditional response of punitive action with its focus on an individual committing an error has been ineffective. Systems must be designed to lessen the opportunity for errors to occur and make it easier for people to do the right thing.

Nurses are educated with the mantra of the five rights of medication administration the right patient, the right drug, the right dose, the right route, and the right time. However, the act of administering a medication is only one action in a long series of multidisciplinary tasks predetermined by the institution in which they occur. Because this process has multiple steps and hand-offs, a systems design must be implemented to ensure patient safety. A nurse, however, cannot be absolved of negligence in the administration of medications and is accountable for the regulations set forth by the Massachusetts Board of Registration in Nursing. 

Prevalence of Medication Errors

Results from studies in Colorado and Utah indicate medical errors cause death to at least 44,000 Americans each year. (IOM 1999)  Another study reported in 1991 in New York State suggests the total (medical deaths) may be as high as 98,000 deaths nationally with medication errors accounting for up to 14,000 deaths annually.(IOM 99).  Mason (1999) cites a 1993 study published in the Quality Review Bulletin stating that approximately one million medication errors occur annually with about 120,000 resulting in death. Bates et al (1995) (1997) in their Adverse Drug Event Prevention Study determined the overall rate of adverse drug events (ADE) was 6.5 per 100 hospital admissions with 28% deemed preventable. Leape et al (1995) revealed that in an additional 5.5% of patients, potential ADE’s were averted by chance or interception of an error. 

Lazarou, Pomeranz, & Corey (1998) focused on two separate populations in their study. Included were those admitted to the hospital due to an adverse drug reaction (ADR) and those experiencing an ADR while hospitalized. They estimated that 106,000 hospital patients died in 1994 due to an Adverse Drug Event. This category includes error in all steps of a medication system. In addition to the human costs, research indicates that ADRs result in an additional 1.56 to 4 billion dollars in direct hospital costs per year in the United States. Even more alarming is the conclusion that ADR’s may rank as the fourth to sixth leading cause of death. (IOM 99)

These statistics are demoralizing for health care professionals who set a standard of 100% accuracy as their goal. Mason (1999) states that our institutions are committed to systems that expect human error not human perfection and fail in their organizational accountability to develop systems that reflect practice standards. William Richardson, chair of the committee that wrote “To Err is Human” stated in the press release (IOM, 11/29/99, on-line), “We must have a health system that makes it easy to do things right and hard to do them wrong.”

In 1997, in response to the alarming number of sentinel events occurring in the State of Massachusetts, the Department of Public Health hosted a gathering of all stakeholders in health care. The Massachusetts Coalition for the Prevention of Medical Errors (1997) was formed and included the professional organizations for medicine, pharmacy, and nursing; the hospital association; all pertinent regulatory licensing boards; insurers; governmental accrediting agencies and selected hospitals. The group’s initial objective was to develop a set of principles and best practice recommendations for health care institutions with varied resources, capabilities, and needs. 

In 1998, the Coalition issued their first initiative, Best Practice Recommendations to Reduce Medication Errors, based on the Massachusetts Hospital Association medication error prevention project. The document addressed two recommendations, (1) adopt a systems-oriented approach to medication error reduction, and (2) promote a non-punitive atmosphere for reporting of errors which values the sharing of information about the causes of errors and strategies for prevention. Through consensus building groups and practice experts, best practices have been developed to address short-term recommendations for medication administration processes and procedures.( Mass Coalition) Long-term recommendations target computerization of order entry, computerized pharmacy checks and balances, computer-generated medication administration records, and bar coding of medications.

Best practice guidelines, published in 1999, addressed wrong-route errors specific to actual incidences that occurred within the Commonwealth. In January 2000, best practices for improved prescription order writing were approved by the Coalition. All best practice recommendations provide suggestions related to the avoidance of errors. Buerhaus (1999), in a published interview with Lucian Leape of the Harvard School of Public Health addressed the causes and prevention of errors and concludes with the premise that to prevent errors you redesign the system, not the people.

Association Position

The Massachusetts Nurses Association/Congress of Nursing  Practice, is deeply committed to furthering awareness within the nursing community of the implications of medication errors for society as a whole and for the individual’s licensure and nursing practice.

The Massachusetts Nurses Association/Congress of Nursing Practice believes that education is empowerment. Empowerment enables the nursing community to guide their institutions in the creation of safer systems for medication administration through active participation in the development of medication specific policies and procedures.

The Massachusetts Nurses Association/Congress of Nursing Practice acknowledges that there are contributing factors in the health care workplace that have significant implications for the occurrence of medication errors among nursing professionals. The factors are identified as follows: insufficient nurse staffing, “floating” to an unfamiliar unit, lack of proper orientation to a process or area (competency training), mandatory overtime beyond regularly scheduled work hours, and the procurement of temporary nurses unfamiliar with the institution.  For these reasons, the Massachusetts Nurses Association recommends legislation assuring safe staffing and prohibiting mandatory overtime as well as education of all nurses on whistle blower protection which defends the right of nurses to speak out against unsafe systems of care.  In support of nurses’ rights, the Congress recommends that all institutions adopt voluntary non-punitive reporting systems.

Further, The Massachusetts Nurses Association/Congress of Nursing Practice recommends that all nurses:
 

  • Support the current recommendations of the Massachusetts Coalition for the Prevention of Medical Errors and the approved Best Practice Guidelines. 
  • Practice the Six Rights for Nurses. (Colleran-Cook, 1999)
  • Support establishment of a non-punitive environment in the work place that restricts punitive approaches to those committing error.
  • Support the development of a team approach (nurse-pharmacist-physician committees) to reduce error.

The Massachusetts Nurses Association/Congress of Nursing Practice recommend that all health care institutions:

  • Require clear, legible, and complete medication order writing or printing from all practitioners licensed to prescribe.
  • Require distribution of educational materials for all new medications approved by the institution to team members.
  • Encourage nursing participation on Pharmacy/Therapeutics and Nursing/Pharmacy    Committees. 
  • Use root cause-analysis when investigating medication errors.  
  • Adopt a non-punitive environment within their facility. 
  • Abandon the culture of blame. 
  • Adhere to and implement the recommendations and best practices of the Coalition for the Prevention of Medical Errors. 
  • Honor nurses conscientious efforts to protect their professional licenses.

The Massachusetts Nurses Association/Congress of Nursing Practice supports and encourages:  

  • Research that investigates approaches to safe and improved medication administration systems.
  • The continuation of the activities of the Massachusetts Coalition for the Prevention of Medical Errors in spearheading patient safety advances.
  • The establishment of a national mandatory reporting center for medical errors.
  • The advancement of consumer strategies that empower the role of the public to reduce safety concerns associated with hospital admissions. (Smith, 1998)

The advancement of strategies that enhance the role of patients and families in protecting safe patient care.

Rationale

The problems discussed, herein, have become a national mark on the countenance of the most prosperous, medically advanced nation in the free world. The frequency of medication errors and the implications for  both patient and practitioner are staggering. As stated above in a quote from Lucian Leape’s interview, we must redesign the system and not the people. As Massachusetts has led the nation in remorse for its medication errors may it now lead the nation in reform of a flawed system. 

This position statement was developed in conjunction with the Congress of Nursing Practice, MNA and a Clinical Practicum for Saint Joseph College, Standish ME, Master of Science in Nursing Program. It has utilized the Massachusetts Coalition for the Prevention of Medical Errors established recommendations for health care in the Commonwealth of Massachusetts and beyond.

References

Bates, D. W., Cullen, D. J., Laird, N., Petersen, L. A., Small, S. D., Servi, D., Laffel, G., Sweitzer, B. J., Shea, B. F., Hallisey, R. Vander Vliet, M., Nemeskal, R., & Leape, L. L. (1995). Incidence of adverse drug events and potential adverse drug events. JAMA, Vol 274, No. 1, 29-34.

Bates, D. W., Spell, N., Cullen, D. J., Burdick, E., Laird, N., Petersen, L. A., Small, S. D., Sweitzer, B. J., & Leape, L. L. (1997). The costs of adverse drug events in hospitalized patients. JAMA, Vol 277, No. 4, 307-311.

Buerhaus, P. I. (1999). Lucian Leape on the causes and prevention of errors and adverse events in health care. Image: Journal of Nursing Scholarship, Vol. 31, No. 3, 281-286.

Colleran-Cook, M. (1999). Six rights for nurses administering medications. Massachusetts Nurse. June 1999.

Institute of Medicine, (1999) Preventing death and injury from medical errors requires dramatic, system-wide changes. (On-line: 11/29/1999) http://www4.nationalacademies.org/news.nsf/isbn 

Institute of Medicine, (1999). To err is human: building a safer health system. Washington, D.C. National Academy Press. Executive summary (on-line) http://www4.nas.org 

Lazarou, J., Pomeranz, B. H., & Corey, P. N. (1998). Incidence of adverse drug reactions in hospitalized patients. JAMA, Vol 279, No. 15, 1200-1205.

Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., Hallisey, R., Ives, J., Laird, N., Laffel, G., Nemeskal, R., Petersen, L.A., Porter, K., Servi, D., Shea, B, F., Small, S. D., Sweitzer, B. J., Thompson, B. T., & Vander Vliet, M. (1996). JAMA, Vol 274, No. 1, 35-43.

Mason, D. J. (1999). On human perfection. AJN, Vol 99, No. 3, 7.

Massachusetts Coalition for the Prevention of Medical Errors (1997). MHA best practice recommendations to reduce medication errors: executive summary. (On-line) http://mhalink.org 

Massachusetts Coalition for the Prevention of Medical Errors (2000). Safety first: improving prescription order writing. (On-line) http://mhalink.org 

Smith, D. (1998). Medical error and patient injury: costly and often preventable. Public Policy Institute American Association of Retired Persons. September, 1998.

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