Sunday, October 2, 2011

Verdict on Medication Errors Depends on Workplace Culture

Medication errors are a tough subject.

There probably isn’t a nurse alive who hasn’t “committed” one and none of us enjoys talking about it.

Each year, about 7,000 people die because of medication errors in hospitals, according to the Interdisciplinary Nursing Research Institute. These mistakes cost hospitals $2 billion annually. And while nurses are responsible for about half of the errors, they also are responsible for intercepting 86 percent of the errors.

According to the Institute of Medicine, a hospital patient, on average, can expect to be subjected to at least one medication error each day.

I’m not sure how researchers arrived at that statistic – it seems unrealistically high to me –but we know that mistakes are made by even the most conscientious nurses for all kinds of reasons.

Years ago, nurses were more likely to be fired almost immediately if they made medication errors. Today, however, many hospitals and nursing homes are not so quick to blame the individual. Instead, many are examining their institutional systems and protocols to see if they are inherently flawed.

It’s important that nurses know what constitutes an error. Ask them and most consider a skipped medication a mistake, but a late med because a patient has left the floor doesn’t seem to qualify. Also, nurses want to know that, if they discover an error, there will be some sort of good that results from the report.

Changing workplace cultures, including attitudes about medication errors, can take years, some experts say. My guess is that it would take a few positive drug-reporting scenarios before nurses trust administration enough to feel that there will be no retribution for reporting mistakes of any kind. Administrators need to encourage nurses to report problems, and to recognize them in a positive manner when they do. Administrators also should recognize that when mistakes compromise patients’ health, it’s traumatizing to nurses as well, and that nurses may need counseling.

It could be that when mistakes happen, it’s time to look closely at systems, policies and protocols, and to share the findings. It also might be a good idea for hospitals to share information on problems and solutions so that each institution doesn’t have to re-invent the wheel.

Have you ever made a medication error or other mistake?

Have you been present when a co-worker made an error? If so, did you feel an obligation to report it?

How was the incident handled by administration?

Did the incident become a learning experience for the staff or was the employee held up as an example of incompetency?

Did the mistake result in revamping protocols?

Tell us about it.

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