Medication Errors at Medical Facilities
Cause Mapping Example:
A
2006 report from the Institute of Medicine of the National Academics says preventable medication errors harm 1.5 million people every year, and cost at least $3.5 billion in extra medical costs to treat drug error-related injuries. According to the
Institute of Medicine National Academy Press' To Err is Human: Building a Safer Health System (2000), medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths. When do these errors happen? According to a
1995 Journal of American Medical Association (JAMA) study, 39% of medication errors occur during prescribing; 12% occur during transcribing at the pharmacy; 11% occur during compounding at the pharmacy, and 39% occur during administration. From the perspective of a medical facility, what are the causes of medication errors adminstered while at a medical facility, and what can be done? (
Click here to view a patient perspective on preventing medication errors.)
We will look at this problem in a proactive Cause Map (visual root cause analysis). What this means is instead of waiting for a problem to occur and looking for the causes of that specific incident, we look at many ways that medication errors COULD occur and will look for solutions to reduce the risk of all types of medication errors.
Step 1. Define the Problem
The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? Here we're discussing medication errors, which is our problem. Because this is a proactive investigation, there's no specific when. For the where, we are specifically looking at medication errors that occur at a medical facility during prescribing, preparing and administering medications.
Next we define the impacts to the goals. Because this is a proactive map, the impacts to the goals are potential impacts. For example, a medication error has the potential to cause a patient death or serious harm to a patient. Additionally, there is the potential for legal action against involved employees (employee impact goal) or the medical facility (organization goal). Medication errors are "never events" which are an impact to the compliance goal. The patient receiving the wrong type or dose of medication is an impact to the patient services goal.
Step 2. Identify the Causes (The Analysis)
We begin the Cause Map by writing down the goals that were affected as defined in the problem outline. For medication errors, the patient safety goal is impacted because of the potential for patient death or serious harm. This is the first cause-and-effect relationship in the analysis.
The analysis can continue by asking Why questions and moving to the right of the cause-and-effect relationship above. Here the Why question leads to the causes of patient death or serious harm. Here, the potential for patient death or serious harm is the patient receiving the wrong type or dose of medication. This is also the cause of the impact to the patient services goal.
The patient receives either the wrong medication, the wrong dose of medication, or does not receive needed medication. We'll look at each of these in turn.
First, however, it looks like we're going to start getting into a process issue. At this point, let's take a break from our Cause Map and build a Process Map for the Medication Administration Process. We can begin with an extremely simple Process Map. Medication is prescribed, prepared, and then given to the patient.
We can add much more detail to this map. First let's break down the "Medication prescribed" step in more detail. First, the physician determines that the patient needs medication. The physician selects the type of medication, the dose of the medication, and then writes or enters the prescription. The physician then explains the prescription to the patient and the prescription is delivered to the pharmacy.
Next the pharmacist takes over and we get to the "Medication prepared" step. The pharmacist selects the medication, measures the medication and then the medication is delivered to the nurse.
Now the nurse takes over for the "Medication given to patient" step. The nurse takes the medication to the proper area (department, ward, room, etc) and then the medication is given to the patient.
Because we are attempting a proactive root cause analysis, we can look at the Process Map for steps that could go wrong. The doctor might select the wrong medication, the wrong dose, write the wrong medication or dose on the prescription, or the doctor might not tell the patient about the prescription.
The pharmacist might grab the wrong medication, or incorrectly measure the medication.
The nurse may grab the wrong dosage or the wrong medication. The wrong medication may be given to the patient, or the medication may be given to the wrong patient. (By the way, are these the only ways medication errors can be made? Not even close, but it'll do as a starting point.)
Now that we've identified some potential pitfalls, we can go back to our Cause Map. A patient may receive the wrong medication when a nurse gives the wrong medication to the patient (step #11 from the Process Map) and the patient doesn't speak up about receiving the wrong medication. A patient might not speak up because the patient doesn't know what the medication is for, because the doctor did not explain the medication to the patient (step 5).
The nurse gives the wrong medication to the patient because of an ineffective check of the medication. (How do we know it was ineffective? Because the patient got the wrong medication.) In addition to the ineffective check, the nurse may either grab the wrong medication off the cart (step 10) or be given the wrong medication. Recent studies have shown that errors at this stage in the process (when a nurse is administering medication) are frequently caused by interruptions that occur during the task.
The nurse may be given the wrong medication because the prescription was filled incorrectly or because the prescription was for the wrong medication.
The prescription may be filled incorrectly if the pharmacist grabs the wrong medication (step 10), possibly due to similar looking bottles on the self. Or the pharmacist may misinterpret the prescription, likely due to illegible handwriting. In addition, in order for a prescription to be filled incorrectly requires an ineffective check of the prescription.
Having a prescription for the wrong medication also requires an ineffective check. In addition, the doctor may have written the prescription out incorrectly (step 4) or selected the wrong medication (step 2). Both may be caused by similar sounding names.
Once all these causes have been identified, the next step is to identify solutions to reduce the risk.
Step 3. Select the Best Solutions (Reduce the Risk)
Any cause from the Cause Map may have a possible solution, or potential solutions. Potential solutions should be identified for as many causes on the map as possible. Once the potential solutions have been identified, the next step is to identify the solutions that will best reduce the risk for the organization involved. These solutions become action items. Following are some action items that have been put into place by various organizations in order to reduce the risk of medication errors.
Solutions 2, 5, 7 and 10 are all process solutions - that is, they add or change steps in the process. Here's what the new process would look like once these action items have been implemented. Steps in blue have been added.
Click here to download the Microsoft Excel workbook showing the outline, Cause Map, and Process Maps discussed above.