Getting Smart on Medication Errors

by R. Clark Campbell, MSN, RN-BC, Member, HIMSS Innovation Committee, and San Antonio Chapter of HIMSS

Do you agree with the following: One of the best ways to prevent medication errors is to educate the staff?  How about this: Incompetent staff cause medication errors?

I have a definite opinion about the above.  I think most people agree with the first, but balk at the second.  I think both statements are equivalent.  And both are wrong.

Ask yourself: What is often the first response when the results of a root cause analysis are revealed?  “Educate the staff.”  Give me a break.

Allow me to defend my statement.  Here are the four events that led to my position.

  • Don Norman’s class on cognitive psychology at UC San Diego: How DO we think?  What causes errors?
  • My first medication error as an RN; I didn’t mean to give them the wrong dose!
  • Being a construction site safety manager. Why has OSHA been so successful in reducing job site injuries?
  • Ross Koppel’s NEJM article The Role of CPOE in Facilitating Medication Errors. You mean technology makes things WORSE?

From these events, I changed my way of looking at medication errors, and I came up with a simple method that you can use to get this point across to other nurses.  I have used this in small classes and national meetings with equal effectiveness.

1.  Ask anyone who has ever given medication to a patient to stand up.

2.  Ask them to recite the five rights (the big five, not the Johnny come lately’s).

3.  Have everyone sit down who has NOT made a medication error. Typically, no one sits down.

4.  Ask the group if their error violated one of those five rights (of course it did, or it wouldn’t be an error).

The point:  All of us, who made these errors, knew the right thing to do, and didn’t do it. 

Thus, we don’t have a knowledge retention problem; we have a knowledge application problem.  Or, as one of my co-workers once put it, “We set people up to fail, and then, slap them when they do.”

The evaluation of process, the way a nurse or other medical professional gets from “data to wisdom,” is the heart of informatics.  We owe it to our partners in care to continuously look at removing barriers to effective and efficient care. 

I don’t think technology is the largest part of the solution.  What do you think?  How to you solve the “knowledge application” problem?

R. Clark Campbell, MSN, RN-BC, is Chief of Medical Informatics at Brooke Army Medical Center in San Antonio, Texas.  At present, a member of the HIMSS Innovation Committee, he is a past member of the Nursing Informatics Committee and an active member of the San Antonio HIMSS Chapter.

About Christel Anderson

Christel Anderson, is HIMSS Director, Clinical Informatics
This entry was posted in Health IT Workforce, Nursing Informatics and tagged , , , , . Bookmark the permalink.

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