They serve as a good reminder that double checks remain weak solutions in any root cause analysis. Human error rates in many industries show error rates of 10% or higher when someone checks the work of someone else. So even though you should not abandon your double checks before medication administration, you must have other protections in place as well.

Secondly, Joint Commission requires facilities to incorporate failure mode and effects analysis (FMEA) into their quality improvement activities. When we are asked what problems a facility might consider for a FMEA, hi-alert drugs are always at the top of our list. Doing FMEA for processes related to anticoagulants is important not only in helping to prevent errors but may also be very valuable in helping you to respond quickly and appropriately to prevent patient harm in the event that such an error actually occurs.

Thirdly, Joint Commission also requires organizations systematically review look-alike/sound-alike medications as part of their medication safety program. Too many organizations spend most of their time on the “sound alike” portion and not enough time on the “look alike” side, especially looking at packaging and labeling.

A fourth lesson is more philosophical. There are certain medications that clinical staff often don’t consider to be ”medications”. Heparin flushes are probably one of those. IV solutions are another. We need to do a better job of reminding staff about all potentially dangerous things.

Fifthly, automated dispensing machines have been a godsend for most organizations and have undoubtedly contributed to improvement in both efficiency and patient safety. However, they do bring their own set of potential problems. Organizations should be looking to ensure that they are tied to other technological patient safety initiatives such as barcoding and computerized physician order entry (CPOE). In the meantime, consider them as another topic for FMEA.

Lastly, each organization needs to think about how it responds to alerts that are put out by critical incidents occurring anywhere. Don’t wait for something bad to happen at your facility. Make sure that part of your routine patient safety activities is responding to alerts put out by the FDA, ISMP, Joint Commission, your state Department of Health, or other reputable organizations that issue alerts. One item on your monthly quality improvement/patient safety agenda should be “Industry Alerts and Concerns” and someone should be charged with scanning the appropriate resources for such alerts.

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Andrew

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For now, here’s the link.

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