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Revised National Patient Safety Goal on medication handling
Patient Safety First
APRIL 2006, VOL 83, NO 4
PATIENT
SAFETY
FIRST
Revised National Patient Safety Goal on medication handling
T
he Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO’s) Sentinel Event database identifies medication errors as one of the most frequently occurring threats to patient safety.1 Of the 3,548 sentinel events reported to JCAHO between January 1995 and December 2005, 10.1% (358) were adverse medication events.1 Communication was identified as the root cause of these sentinel events in more than 60% of the cases and procedural compliance as the root cause in nearly 25% of the cases.2 Implementing safe medication practices, therefore, is an important step in ensuring patient safety.
NATIONAL PATIENT SAFETY GOAL 3D Each year, JCAHO releases National Patient Safety Goals that promote specific improvements in patient safety by highlighting problematic areas in health care and describing evidence- and expertbased solutions to these problems. In July 2005, JCAHO released the 2006 National Patient Safety Goals, including Goal 3: Improve the safety of using medications,3 for implementation beginning January 2006. In January 2006, however, JCAHO revised the implementation expectations for requirement 3D, which address labeling requirements for medications and medication containers.3 The wording and criteria for these two implementation expectations were changed slightly to require the following. • Medication labels should include medication name, strength, amount if not apparent from the container, expiration date when not used within 24 hours, and expiration
Brenda S. Gregory Crum, RN
time when expiration occurs in less than 24 hours.4 • All labels should be verified both verbally and visually by two qualified individuals when the person preparing the medication is not the person administering the medication.4 Goal 3D specifically focuses on medications transferred to the sterile field or removed from original containers for use by another individual.
PERIOPERATIVE MEDICATION ERRORS Although medication In January 2006, errors involving the perioperative continuum of the Joint care are infrequently described in the literaCommission ture, the available studies show that medication revised the errors are prevalent in the OR and are significantly implementation harmful when they occur.5 Consider the folexpectations for lowing scenarios. • A staff member reNational Patient arranges medications on the back table while Safety Goal relieving a team member for a break. After requirement 3D, returning from his break, the original team which addresses member does not notice that the medicamedication tions have been rearranged and draws up labeling. the incorrect medication for use, assuming the medications were where he left them. • A surgeon picks up a syringe and draws up a solution that she believes is prepared for injection, only to find out too late that it is the incorrect medication. Although the medication container was labeled AORN JOURNAL •
955
Patient Safety First
APRIL 2006, VOL 83, NO 4
correctly, the label has fallen off, so the surgeon mistakenly injects the patient with a harmful medication. There are anecdotal reports from ORs, same day surgery centers, emergency departments, cardiac catheterization laboratories, interventional radiology departments, and other areas about • use of unlabeled medications or solutions during a procedure because there is only one medication on the field, • labels that disintegrate or fall off the administration tool (eg, asepto, syringe) when the tool is placed in a container holding the solution to be administered, • medication labels that are illegible because of handwriting or ink that runs and smears, and • medication labels that contain unapproved abbreviations. Variations in practices and labeling methods, lack of a visible label, the need to remove medications from their original containers to transfer them to the field, the fast pace within the department, and procedures that require staff member changes are factors that can result in faulty communication, lack of compliance, and errors.
EVALUATING MEDICATION LABELING PRACTICES Most health care settings have required medication labeling for years, but near misses and serious events con-
956 • AORN JOURNAL
Most health care settings have required medication labeling for years, • consistent labeling of all but near misses and medications and solutions on and off the sterile field; adverse events • intactness of labels on all containers; and continue to occur. • availability of original tinue to occur. Health care facilities should develop standardized and redundant systems for medication handling and delivery to decrease errors and improve outcomes.6 Staff members in each setting must critique their error-prone processes and evaluate verbal and written communication practices for procedural gaps that can hinder compliance with practices. Policies should be developed and supplies made available that promote consistent practices and expectations among all team members. Practices that should be evaluated include • hand-off processes using verbal and visual verification between those delivering and administering medications and before and after personnel relief; • medication labeling that is complete and includes the required information (ie, medication name, strength, amount, and expiration dates and times when appropriate); • handwriting and misspelling; • misuse of abbreviations; • ready availability of easyto-read medication labels; • use of medication labels that are legible and visible to all team members;
medication containers for reference during the procedure when a medication has been removed from its original container. Critiquing high risk practices is necessary to identify opportunities for improvement. Labeling requirements identified in the National Patient Safety Goals are intended to increase communication through accurate and complete documentation of information. Labels should replicate those on the original container to prevent any opportunity for mix-ups. Avoiding shortcuts, such as writing “bupivicaine with epinephrine” instead of “bupiv S epi,” may increase writing time but could prevent confusion when a health care practitioner looks at a container quickly. The medication name and strength, including the unit of measurement (eg, percentage, units, grams, mL), should be easily visible on basins, aseptos, syringes, and IV lines that extend onto the sterile field. The medication amount might be required if medications are mixed on the field (eg, an antibiotic that is mixed in a specific amount of saline; tumescent solution that is a mixture of 1,000 mL lactated Ringer’s solution, 500 mg lidocaine, and 1 mg epinephrine). If the medication amount is different than the
Patient Safety First
APRIL 2006, VOL 83, NO 4
Health care practitioners should verbally identify the medication name and strength when passing it to the person who will administer it to the patient. amount in the original container, it should be labeled on the field. Expiration date and time are less applicable in perioperative settings because medications on the sterile field commonly are used before they expire and discarded if they remain on the field for long periods of time. In rare instances, however, a medication must be used in a certain period of time after it is prepared or reconstituted (eg, chemotherapeutic agents), and expiration date and time of these medications should be labeled on the field. Verbal communication practices also should be improved. Facilities should establish a standard of practice for communicating all patient care information, including medications and solutions to be administered, for personnel who are relieved for breaks and at change of shift. Medications commonly may be administered by a third party who does not see the original medication container or delivery of the medication to the field, so two qualified personnel always should verify the information from the original medication container, including name, strength, and expiration date, as compared to the label that is prepared. Another step that should be followed is for the health care practitioner to verbally identify the medication name and
strength when passing it to the person who will administer it to the patient.
BARRIERS TO PRACTICE CHANGES There are many barriers to implementing safer practices in health care settings. A common barrier is the belief that current practices are satisfactory to ensure patient safety without investigating pitfalls. Respondents to a recent survey reported cost as a major reason for not implementing specific medication safetyrelated techniques.7 Improving safety requires 100% commitment from health care facility administrators and staff members, including implementing changes in practice and providing tools to meet the needs of health care practitioners. In an environment where turnover time between procedures is a measurement of quality and staff members simply trust that each person has fulfilled their expected responsibilities, health care practitioners are challenged by the need to take extra time to promote safe practices. Adequate communication and correct medication labeling, however, could prevent an error from occurring. ❖ BRENDA S. GREGORY CRUM RN, MSN, CNOR SAFETY AMBASSADOR SANDEL MEDICAL INDUSTRIES, LLC CHATSWORTH, CALIF
NOTES 1. “Sentinel Event Statistics: As of December 31, 2005,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/NR/rdonlyres /6FBAF4C1-F90E-410C-8C1D5DA5A64F9B30/0/se_stats_1231 .pdf (accessed 7 March 2006). 2. “Root Causes of Medication Errors (1995-2005),” Joint Commission on Accreditation of Healthcare Organizations, http: //www.jcaho.org/NR/rdonlyres /CA846F8C-E531-4334-8079-16203 FB3857C/0/se_rc_medication_errors .gif (accessed 7 March 2006). 3. “Facts about 2006 National Patient Safety Goals,” Joint Commission on Accreditation of Healthcare Organizations, http://www .jcaho.org/PatientSafety/National PatientSafetyGoals/06_npsg_facts .htm (accessed 7 March 2006). 4. “Joint Commission 2006 National Patient Safety Goals Implementation Expectations,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/NR/rdonlyres /DDE15942-8A19-4674-9F3BC6AE2477072A/0/06_NPSG_IE .pdf (accessed 7 March 2006). 5. B Goeckner et al, “Differences in Perioperative Medication Errors With Regard to Organization Characteristics,” AORN Journal 83 (February 2006) 351-368. 6. “AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span,“ in AORN Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2006) 321-327. 7. M M Casey, I Moscovice, G Davidson, “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety,” Upper Midwest Rural Health Research Center, http://www.upper midwestrhrc.org/pdf/medication _safety.pdf (accessed 17 Feb 2006).
AORN JOURNAL •
957
APRIL 2006, VOL 83, NO 4
PATIENT
SAFETY
FIRST
Revised National Patient Safety Goal on medication handling
T
he Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO’s) Sentinel Event database identifies medication errors as one of the most frequently occurring threats to patient safety.1 Of the 3,548 sentinel events reported to JCAHO between January 1995 and December 2005, 10.1% (358) were adverse medication events.1 Communication was identified as the root cause of these sentinel events in more than 60% of the cases and procedural compliance as the root cause in nearly 25% of the cases.2 Implementing safe medication practices, therefore, is an important step in ensuring patient safety.
NATIONAL PATIENT SAFETY GOAL 3D Each year, JCAHO releases National Patient Safety Goals that promote specific improvements in patient safety by highlighting problematic areas in health care and describing evidence- and expertbased solutions to these problems. In July 2005, JCAHO released the 2006 National Patient Safety Goals, including Goal 3: Improve the safety of using medications,3 for implementation beginning January 2006. In January 2006, however, JCAHO revised the implementation expectations for requirement 3D, which address labeling requirements for medications and medication containers.3 The wording and criteria for these two implementation expectations were changed slightly to require the following. • Medication labels should include medication name, strength, amount if not apparent from the container, expiration date when not used within 24 hours, and expiration
Brenda S. Gregory Crum, RN
time when expiration occurs in less than 24 hours.4 • All labels should be verified both verbally and visually by two qualified individuals when the person preparing the medication is not the person administering the medication.4 Goal 3D specifically focuses on medications transferred to the sterile field or removed from original containers for use by another individual.
PERIOPERATIVE MEDICATION ERRORS Although medication In January 2006, errors involving the perioperative continuum of the Joint care are infrequently described in the literaCommission ture, the available studies show that medication revised the errors are prevalent in the OR and are significantly implementation harmful when they occur.5 Consider the folexpectations for lowing scenarios. • A staff member reNational Patient arranges medications on the back table while Safety Goal relieving a team member for a break. After requirement 3D, returning from his break, the original team which addresses member does not notice that the medicamedication tions have been rearranged and draws up labeling. the incorrect medication for use, assuming the medications were where he left them. • A surgeon picks up a syringe and draws up a solution that she believes is prepared for injection, only to find out too late that it is the incorrect medication. Although the medication container was labeled AORN JOURNAL •
955
Patient Safety First
APRIL 2006, VOL 83, NO 4
correctly, the label has fallen off, so the surgeon mistakenly injects the patient with a harmful medication. There are anecdotal reports from ORs, same day surgery centers, emergency departments, cardiac catheterization laboratories, interventional radiology departments, and other areas about • use of unlabeled medications or solutions during a procedure because there is only one medication on the field, • labels that disintegrate or fall off the administration tool (eg, asepto, syringe) when the tool is placed in a container holding the solution to be administered, • medication labels that are illegible because of handwriting or ink that runs and smears, and • medication labels that contain unapproved abbreviations. Variations in practices and labeling methods, lack of a visible label, the need to remove medications from their original containers to transfer them to the field, the fast pace within the department, and procedures that require staff member changes are factors that can result in faulty communication, lack of compliance, and errors.
EVALUATING MEDICATION LABELING PRACTICES Most health care settings have required medication labeling for years, but near misses and serious events con-
956 • AORN JOURNAL
Most health care settings have required medication labeling for years, • consistent labeling of all but near misses and medications and solutions on and off the sterile field; adverse events • intactness of labels on all containers; and continue to occur. • availability of original tinue to occur. Health care facilities should develop standardized and redundant systems for medication handling and delivery to decrease errors and improve outcomes.6 Staff members in each setting must critique their error-prone processes and evaluate verbal and written communication practices for procedural gaps that can hinder compliance with practices. Policies should be developed and supplies made available that promote consistent practices and expectations among all team members. Practices that should be evaluated include • hand-off processes using verbal and visual verification between those delivering and administering medications and before and after personnel relief; • medication labeling that is complete and includes the required information (ie, medication name, strength, amount, and expiration dates and times when appropriate); • handwriting and misspelling; • misuse of abbreviations; • ready availability of easyto-read medication labels; • use of medication labels that are legible and visible to all team members;
medication containers for reference during the procedure when a medication has been removed from its original container. Critiquing high risk practices is necessary to identify opportunities for improvement. Labeling requirements identified in the National Patient Safety Goals are intended to increase communication through accurate and complete documentation of information. Labels should replicate those on the original container to prevent any opportunity for mix-ups. Avoiding shortcuts, such as writing “bupivicaine with epinephrine” instead of “bupiv S epi,” may increase writing time but could prevent confusion when a health care practitioner looks at a container quickly. The medication name and strength, including the unit of measurement (eg, percentage, units, grams, mL), should be easily visible on basins, aseptos, syringes, and IV lines that extend onto the sterile field. The medication amount might be required if medications are mixed on the field (eg, an antibiotic that is mixed in a specific amount of saline; tumescent solution that is a mixture of 1,000 mL lactated Ringer’s solution, 500 mg lidocaine, and 1 mg epinephrine). If the medication amount is different than the
Patient Safety First
APRIL 2006, VOL 83, NO 4
Health care practitioners should verbally identify the medication name and strength when passing it to the person who will administer it to the patient. amount in the original container, it should be labeled on the field. Expiration date and time are less applicable in perioperative settings because medications on the sterile field commonly are used before they expire and discarded if they remain on the field for long periods of time. In rare instances, however, a medication must be used in a certain period of time after it is prepared or reconstituted (eg, chemotherapeutic agents), and expiration date and time of these medications should be labeled on the field. Verbal communication practices also should be improved. Facilities should establish a standard of practice for communicating all patient care information, including medications and solutions to be administered, for personnel who are relieved for breaks and at change of shift. Medications commonly may be administered by a third party who does not see the original medication container or delivery of the medication to the field, so two qualified personnel always should verify the information from the original medication container, including name, strength, and expiration date, as compared to the label that is prepared. Another step that should be followed is for the health care practitioner to verbally identify the medication name and
strength when passing it to the person who will administer it to the patient.
BARRIERS TO PRACTICE CHANGES There are many barriers to implementing safer practices in health care settings. A common barrier is the belief that current practices are satisfactory to ensure patient safety without investigating pitfalls. Respondents to a recent survey reported cost as a major reason for not implementing specific medication safetyrelated techniques.7 Improving safety requires 100% commitment from health care facility administrators and staff members, including implementing changes in practice and providing tools to meet the needs of health care practitioners. In an environment where turnover time between procedures is a measurement of quality and staff members simply trust that each person has fulfilled their expected responsibilities, health care practitioners are challenged by the need to take extra time to promote safe practices. Adequate communication and correct medication labeling, however, could prevent an error from occurring. ❖ BRENDA S. GREGORY CRUM RN, MSN, CNOR SAFETY AMBASSADOR SANDEL MEDICAL INDUSTRIES, LLC CHATSWORTH, CALIF
NOTES 1. “Sentinel Event Statistics: As of December 31, 2005,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/NR/rdonlyres /6FBAF4C1-F90E-410C-8C1D5DA5A64F9B30/0/se_stats_1231 .pdf (accessed 7 March 2006). 2. “Root Causes of Medication Errors (1995-2005),” Joint Commission on Accreditation of Healthcare Organizations, http: //www.jcaho.org/NR/rdonlyres /CA846F8C-E531-4334-8079-16203 FB3857C/0/se_rc_medication_errors .gif (accessed 7 March 2006). 3. “Facts about 2006 National Patient Safety Goals,” Joint Commission on Accreditation of Healthcare Organizations, http://www .jcaho.org/PatientSafety/National PatientSafetyGoals/06_npsg_facts .htm (accessed 7 March 2006). 4. “Joint Commission 2006 National Patient Safety Goals Implementation Expectations,” Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/NR/rdonlyres /DDE15942-8A19-4674-9F3BC6AE2477072A/0/06_NPSG_IE .pdf (accessed 7 March 2006). 5. B Goeckner et al, “Differences in Perioperative Medication Errors With Regard to Organization Characteristics,” AORN Journal 83 (February 2006) 351-368. 6. “AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span,“ in AORN Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2006) 321-327. 7. M M Casey, I Moscovice, G Davidson, “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety,” Upper Midwest Rural Health Research Center, http://www.upper midwestrhrc.org/pdf/medication _safety.pdf (accessed 17 Feb 2006).
AORN JOURNAL •
957