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Learn from medication errors to prevent history from repeating

Staff Development Weekly: Insight on Evidence-Based Practice in Education, July 14, 2006

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Developing effective policies and procedures to internally handle medication errors is important not only to comply with accreditation standards, but also to prevent staff from repeating the same mistakes in the future. If handled properly after it occurs, a medication error can help you identify flaws in your procedures and educate staff about safety.

Barb Struthers, clinical director at Northwest Michigan Surgery Center in Traverse City, MI, and Patricia Lombardo, administrator at Eastern Pennsylvania Endoscopy Center in Allentown, PA, offer the following tips for handling a medication error:

• Identify the error. The most successful tools for identifying a medication error are reports from staff, says Struthers. Encourage the individual responsible for the error or the first person to identify an error to fill out an occurrence report, detailing the time of the error and its severity.
• Investigate the incident. The investigation may be the most important phase of handling a medication error because it can help determine whether the error was caused by a human mistake or a systemic flaw that could lead to further errors, Lombardo says.

The investigation often includes a combination of reviewing charts and interviewing the employees involved. Depending on the severity of the error, you may also need to conduct a more in-depth root-cause analysis, says Lombardo.

To get more tips, go to Briefings on Ambulatory Accreditation (BAA). For the cost of just three stories, you can get the entire July issue of BAA. Click here to choose between the PDF and HTML versions for just $30. Subscribers to the online version of BAA have free access to this article. Subscribers to the print newsletter can find this article in their July issue.

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