You wouldn’t know it by looking at headlines that read “Nurse Incarcerated for Administering Wrong Dose Medication” or “Pharmacist on Trial for Manslaughter” but, 90% of medication errors are due to a failed system, not the proactive negligence of clinicians.
Let’s face it; you never read headlines like “System Failure at Madeup Hospital Causes Wrongful Death”. Why? Because the general public and mainstream media have no idea the nuances that make up a system within the units of a hospital. Most people have no idea that one hospital unit may be run completely different than a neighboring unit.
I only understand it because my job requires me to, and if I didn’t have hospitals for clients, I would have no idea what the system is referring to.
Since I am not a clinician, I will attempt to outline the top hospital inefficiencies that we see in the hospitals we work with in order to educate my hospital friends and the public:
1.) Medication Receipt– this is when an order is sent to pharmacy and is not received on time. In order to administer a medication at the right time, the nurse will re-order the medication. Most often, nursing ends up receiving two orders and now has to send one of them back causing pharmacy to process a credit for the double processed medication order. Some organizations have a full-time employee just to process medication credits.
2.) Documentation - on a typical assessment, we find that nursing spends up to an hour organizing and documenting patient data before her shift even begins. She then spends another hour documenting medications and administration data. This is taking her away from her time at the bedside taking care of the patient. More shockingly though, a lot of nurses have their own document. A "cheat sheet" if you will, which lacks standardization and consistency.
3.) Hunting - hunting down a medication or supply because it is either not in the patient’s drawer or has not been received from pharmacy is one of the biggest things we see. The nurse will go searching in her own unit or neighboring unit to find the supplies, thus leaving another patient or unit with a missing medications and/or supplies only to cause the hunting process all over again through the perpetuation of the missing meds and/or supplies.
4.) Extended Length of Stay – ever see a patient wake up in a hospital bed and be willing to chew through the walls to get out of there? Well, greater than needed length of stay is the fourth major inefficiency that we see all over the country. Greater length of stay means increased cost, risk of hospital infections and exposure to medication errors. One of the most efficient changes we have seen in addressing this is the implementation of multi-disciplinary rounds (but that’s a whole other story).
5.) Technology Readiness – It is absolutely necessary for the medication process to be standardized in order to optimize technology investment. The wasted time caused my nurses waiting for access to the automated dispensing cabinet (ADC) alone is good enough argument to address this process. In fact, in a survey conducted by ISMP, 48% of nurses state that “ADCs are not located in areas free from distraction”. This compilation of inefficiencies lends itself to a high risk process that needs serious redesign in our hospitals.
There is a common model in the industry that visually illustrates what happens in a major medical error. It’s called the “swiss cheese model”. It mainly illustrates that when multiple system inefficiencies line up properly, this is when a medication error occurs.
Think of the system as multiple processes that seem so simple (like having the right supply in the drawer, or getting the medication on time) and when multiple inefficiencies happen together, someone gets hurt.
I think its important to understand this in simple terms, especially for those of us who are not practicing clinicians and don't work within the four walls of a hospital. However, I am constantly surprised by how many hospitals we go into who have no clue the kind of system variation that goes on between and within the various units.
We must educate ourselves and our hospital partners so that we, as a teammates (doctors, nurses, pharmacy, patients, cleaning crew, c-suite executives, professional services consultants), can look at this system and never have to read "System Failure in Your Hospital Causes Wrongful Death".
I believe in my work.
Claire
