Nursing

Increase error reporting by taking a nonpunitive approach

Nurse Leader Weekly, September 17, 2004

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Upper Valley Medical Center in Troy, OH, saw an 80% drop in serious medication errors after pharmacy director Thomas Bigley, RPh, MS, began sending staff thank-you notes with an enclosed $2 coupon to the hospital cafeteria in 2000, he says.

The incentives led to an increase in error reports from 15 per month to 70-80 per month, Bigley says. The increased reporting allowed the hospital to look for potential system flaws that could cause the errors, such as a lack of information on the medication administration record that leads a nurse to misread a medication administration time.

Creating a nonpunitive reporting environment will not only lead to increased error reporting, but it can also help you look for potential breakdowns in the medication process. This will help improve safety and show the JCAHO how you handle medication errors and quality improvement.

Fifteen years ago, The Cleveland Clinic maintained an error log book, says David Gragg, RPh, MBA, pharmacy operations manager and medication safety officer. One error report would earn a staff member a warning, two error reports would earn a write-up, and three error reports would warrant a suspension.

That punitive culture prevents hospitals from getting a true sense of what their error rate is, says Diane Cousins, RPh, vice president of the Center for the Advancement of Patient Safety at the U.S. Pharmacopeia (USP). Creating a nonpunitive environment means administrators must make staff feel comfortable when reporting errors and realize that the reports could help improve systems and patient safety, she says.

Now every time a staff member reports an error, Gragg will send a thank-you note with a coupon for a free meal at Pizza Hut. Before the incentive program began four years ago, Gragg would receive 30 error reports per month. That number jumped to 110 per month as the culture became less punitive.

The new culture at Upper Valley Medical Center makes staff more observant, and they look for potential system flaws, Bigley says. For example, one intensive care unit nurse noticed that when nurses gave paralyzing agents to patients on ventilators, the drugs did not have labels that alerted staff that they are high-alert and dangerous medications.

No death or injury occurred because of a mix-up between paralyzing agents and other medications, but an observant nurse helped avert a potential problem.

Tip: Encourage staff to look for potential error and risk points and reward them for improving patient safety.

"You want them to anticipate," Cousins says. "One attribute of a high-reliability organization is to anticipate failure and prepare for it. That's how you can build the safest system."

- Adapted from Hospital Pharmacy Regulation Report (June 2004), published by HCPro, Inc.



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