Pursuing safe medication use and the promise of technology

MedSurg Nursing, April, 2007 by Zane Robinson Wolf

For years, health care providers have been alerted to the prevalence of medical errors and the scope of the problem. The Institute of Medicine's report noted that more people died each year in the United States from medical errors than from highway accidents, breast cancer, or AIDS (Kohn, Corrigan, & Donaldson, 1999). These statistics attracted the notice of many stakeholders. The report also asserted that medication errors were not regarded routinely as a public health problem. Reports about patient deaths and injuries resulting from health care interventions had made almost no impact on clinical practice for decades (Millenson, 2002). Now, however, medical-surgical nurses and other health care providers agree they no longer have the luxury of waiting for perfection in plans to achieve patient safety in medication use systems and other events resulting in notable harm.

Failure to disclose mistakes in the past has been attributed to socialization processes of health care providers (Smith & Forster, 2000). Health care errors in general and medication errors specifically now are very public. Selected cases helped this occur, such as the Dana-Farber Cancer Institute chemotherapy errors and the notoriety achieved with the tragic death of Betsy Lehman, a Boston Globe health columnist. The case attracted the attention of the Institute of Medicine, health care professionals, and their organizations, and highlighted the conflict between scientific research and patient care. It is a tipping point (Gladwell, 2002) for the national concern on medication and other health care errors. Consistent with the characteristics of tipping points, the epidemic that is the alarm regarding patient safety of medication use systems was contagious; seemingly small causes had big effects, and the change happened not gradually but at single, dramatic moments.

After first noticing the public health problem of health care errors, health care professionals were alerted to a new Veterans Administration (VA) "honesty is the best policy" initiative (Kraman & Hamm, 1999). The ensuing discussions stimulated some to consider the possibility that patients and their families have bought into the belief in professional perfection. Moreover, families who have sued health care providers involved in errors have suspected coverups or desired revenge (Hickson, Clayton, Githens, & Sloan, 1992). A change to an explicit policy of disclosure may have started before 1995 in other health care agencies, but has spread throughout the country due to a VA initiative. Medical centers of the VA system inform patients and family members of adverse events and describe the measures that address them as well as the steps taken to minimize negative outcomes to patients or family members. The policy put patients' interests ahead of institutions' and may be relatively inexpensive over the long run (Kraman & Hamm, 1999). Some states have joined this effort by mandating a similar policy (Pennsylvania Economy League, 2005).

"In spite of the fact that health care professionals are 'only human' and are susceptible to making mistakes, there is a prevailing expectation both within and outside the health care professions that medical mistakes are unacceptable" (Smith & Forster, 2000, p. 38). Silence, discounting, denial, and cover-ups are no longer sufficient, even in the case of "near misses" (any error that is detected up to and including the point at which the medication is given to the patient or patient's representative) (Quinlan, Ashcroft, & Blenkinsopp, 2002). However, charges such as criminally negligent homicide in one Colorado case ("Colorado Case Blurs Line," 1997) and other examples such as a Wisconsin case (American Society for Quality, 2005; Green, 2004) serve to increase the fear of health care providers about reporting their mistakes.

One study (Wolf, Serembus, Smetzer, Cohen, & Cohen, 2000) revealed that nurses, pharmacists, and physicians more frequently experienced nonsupportive rather than supportive actions by those in reporting or supervisory relationships following medication errors. Blame and reprimand prevailed. In contrast, managers and administrators cared for patients, reported incidents, and involved risk managers, insurance companies, and other health care providers on behalf of patients. They also warned and taught those who made the errors about drug administration topics, examined policies and procedures, and assumed the responsibility to correct the error. The fears and concerns of health care providers about patient harm, loss of confidence in clinical abilities, and colleague lack of respect could have reinforced residual fears that many were socialized to expect and still harbored. Memories of counseling sessions, reprimands, and embarrassment about mistakes might have prevailed. These findings correspond with other investigations and perspectives about the manner in which health care providers experience health care mistakes following medication error incidents. Efforts to change the culture of blame to one of caring and support might increase error reporting, enhance systems improvement initiatives, and increasingly transform organizational cultures in which participation, risk-taking, and quality improvement strategies flourish (Simpson, 2005).