Medication Safety: The Need of the Hour
  • Posted by Dr. Clive Fernandes
  • 26 Sep, 2014
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Errors in health care are one of the top problems facing the health care industry today. If the current crisis facing health care is not resolved, it would not be long before the segment would be re-titled health careless.

As health care professionals, one of the core principles that we need to follow is Primum non no cere”which when translated means  “First Do no Harm”. And this brings me to the question, do hosptials harm patients? This in itself sounds sacrilegious; how can a hospital – which  is to a patient what a temple is to devotee – harm those who have come to it for refuge and restoration?

In 1999 the Institute of Medicine published the report of its findings“To Err is Human” which estimated that over 98,000 deaths may occur each year as the result of an error in medication. Bear in mind that this number is only for the harm caused by Medication errors. In 2013, the Journal of Patient Safety reported that the deaths caused by Medication errors is about 400,000 deaths in a year. The blizzard of shock over these figures conceals the actual problem.

Especially in face of the tragic reality is the fact that most of these deaths could have been prevented.

With strong emphasis on Medication Management and Use as a result of Accreditation requirements from Accrediting bodies like JCI, NABH, awareness today has improved significantly from what it was a decade ago. Most of the accredited organizations have institutionalized policies and practices that help in improving Medication safety. But if we stop to look at the number of accredited hospitals in our country the number will be abysmally low compared to the number of hospitals across India. Whatever has been reported is merely the tip of the iceberg and we have a long way to go in the area of improving medication safety.

No one would harm a patient knowingly, but haven’t we heard the adage “Bad things do happen in Good hospitals”.  If organizations can understand the reasons why these incidents occur, it would help in reducing the unintentional harm caused to our patients.

Some of the key reasons why errors occur:

  1. Lack of Effective Communication: This is one of the main reasons for errors causing a blight in the healthcare industry. This simply means that the user has not received and assimilated the information in the way it was meant to be followed. Let’s look at it in the context of Medication orders:  if the communication was not effective it could mean the wrong drug , dose,  route or frequency which could lead to a critical outcome. It has been widely accepted that oral communication is one the main causes of errors. Do we encourage Verbal Medication orders? How many times do we see a doctor giving a medication order to another doctor or the nurse over the phone? We know that it is impossible for every medication order to be written down especially in case of emergencies but we would all probably agree that, this in itself cannot condone harm. In this connection we need to implement a fail-safe practice like the READ BACK process wherein the recipient of the information writes down the information and reads it back to the giver who confirms the same before carrying out the order. What about written orders how often are they legible to the extent that they can be interpreted clearly? Have we seen abbreviations in the drug chart or in medication labeling? There have been instances when I have found loaded labeled syringes in the Operating Room, the label reading InjAtr, would that be Atropine, Atracurium or something else? What about the dose and the date of preparation ? So the bottom line is that whatever communication occurs needs to be effective and clear.

     

  2. Is the punitive environment to blame? How do we make a system safe? We can do that by plugging loopholes and system deficiencies, something that we learn when people voluntarily report any medication error they have committed. Do we encourage people to report errors? Do people feel safe reporting errors? There is always that lingering fear in the mind of the health care professional that they would be punished for committing that error. Creating a non punitive environment in the Organization is something that is easier said than done, let’s look back and think when was the last time one of our subordinates reported something back to us that was not as per the policy/ protocol and caused patient harm. What did we do?  At the same time it’s a very thin line and Organizations would need to tread it with caution so that creating a non- punitive environment for voluntarily reporting of errors is not misinterpreted as a sign that committing errors is acceptable or tolerated. Rather staff should realize that voluntary reporting of the error would help us address the process deficiencies that were present and once addressed will prevent the error from happening again.

     

  3. The Battle between meeting Accreditation requirements and creating a safe environment Many Organizations still struggle to find a balance between what needs to be done to improve Medication safety in general versus what they need to do to maintain an accreditation. As a result we see a lot of organizations focussing on the laid down protocols and practices for  six months prior to the audit and then relaxing or ignoring protocols and practices for the next two and a half years only to begin again before the next reaccreditation survey and that’s the time they realise things have drastically changed .

     

  4. Attrition: Being a very dynamic industry there are a lot of challenges with regards to attrition. We often hear statementslike we have these errors or this was not done the way it was supposed to be done because the staff was new and not trained. But attrition is a reality which will not change. It should not be made a reason to compromise on patient safety. It’s a part of life that we need to accept, move on and focus on the job to be done. There needs to be more induction programs, trainings and on the job assessments for new entrants. Patient safety is a continuous 365*24*7 journey and the need of the hour is to make the process more system dependent rather than person dependant, something that is not present as of now.

     

  5. Increased cost: There is generally the cost cutting mantra that is put in by administrators to improve bottom lines and EBIDTA.I am disappointed to say this, but many of the Quality improvement processes come under the scanner first. How often have we heard people say,“why do we need the Clinical Pharmacist to audit the prescription prior to dispensing the medications? The Consultant has prescribed it and he would be right. Can’t the prescribing doctor do the audit?” Do we need to audit all prescriptions? Can we train the nurse to do it? This is so much additional manpower resulting in an increase in cost.

     

Well, we know the answers but still ask the same questions time and again. I agree that we need to improve our efficiencies and top-lines but we need to understand the cost involved. Quality improvement activities need to be proactive rather than retrospective. This will prevent bad things from happening, which I believe will ultimately help EBIDTA and profits as there is no rework and associated costs of dealing with the consequences of medical errors.

 

To sum it up in a sentence – prevention is the key.

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