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The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? We begin the Cause Map by writing down the goals that were affected as defined in the problem outline. The analysis can continue by asking Why questions and moving to the right of the cause-and-effect relationship above. The patient receives either the wrong medication, the wrong dose of medication, or does not receive needed medication.
Because we are attempting a proactive root cause analysis, we can look at the Process Map for steps that could go wrong. The nurse gives the wrong medication to the patient because of an ineffective check of the medication. 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.
Once all these causes have been identified, the next step is to identify solutions to reduce the risk.
Solutions 2, 5, 7 and 10 are all process solutions - that is, they add or change steps in the process. Click here to download the Microsoft Excel workbook showing the outline, Cause Map, and Process Maps discussed above. Matthew Grissinger, RPH, FISMP, FASCPManager, Medication Safety AnalysisPennsylvania Patient Safety AuthorityABSTRACTPennsylvania facilities submitted 879 medication error reports from July 1, 2004, through January 31, 2011, to the Pennsylvania Patient Safety Authority involving patients taking their own medications while in a hospital. According to the Institute of Medicine report, titled “To Err Is Human: Building a Safer Health System”, it was first reported in 1999 that between 44,000 and 98,000 Americans die in hospitals each year due to mistakes in their care. Medical error is clearly the Number One problem in healthcare, contributing to more deaths in the USA than motor vehicle accidents, falls, drowning and plane crashes combined—see Figure 1 below. Most medical errors are related to system problems, not individual negligence or misconduct, and are preventable (see our other Summary Statistic on the preventability of adverse events). Zegers M, Bruijne MC de, Wagner C, Hoonhout LHF, Waaijman R, Smits M, Hout FAG, Zwaan L, Christiaans-Dingelhoff I, Timmermans DRM, Groenewegen PP, Wal G van der.
Anywhere RN™ creates a flexible medication administration process that positively impacts nursing and patient safety.
The latest release of Anywhere RN software features enhanced privacy for patient data and more configurable options to improve patient safety and assist in meeting regulatory requirements. Crowding at the ADCs takes valuable time away from nurses and also limits access for pharmacy. By reducing the number of trips to and from the ADC, Anywhere RN helps reduce the potential for interruptions that can lead to medication errors in nursing, and it frees up more time for patient care. Fewer lines at the cabinet during the medication pass process increases nurse satisfaction. When used with Omnicell's Savvy™ mobile medication workstation, nurses can securely retrieve medications for multiple patients in one trip to the cabinet. More than 180,000 people die every year from hospital errors in Florida and across the country. Here are Five Top Causes of Hospital Negligence in Florida, based on jury verdicts, malpractice insurance claims and research from the American Association of Retired People.
If you suspect that you or a loved one has been a victim of a preventable medical error, contact Florida injury attorney Philip DeBerard.
I've read somewhere that the bad handwriting is due to the very large number of notes that needs to be taken during the education.
The source behind the Time article is a July 2006 report from the Institute of Medicine entitled Preventing Medication Errors: Quality Chasm Series. Some of these “adverse drug events [ADEs],” as injuries due to medication are generally called, are inevitable—the more powerful a drug is, the more likely it is to have harmful side effects, for instance—but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable.
One study calculates, for example, that 800,000 preventable ADEs occur each year in long-term care facilities.
It again considers those numbers low estimates and then notes that none of these studies involve prescriptions that should have happened but never did — errors of omission. Poorly handwritten prescription orders are the chief culprit in miscommunications among prescribing clinicians, nurses, and pharmacists, and have often resulted in serious injury or death due to incorrect understanding of the drug or its dosage, route, or frequency (Cohen, 2000). There was also a note about transcription errors which could be seen as a container for handwriting errors.
The 1.5 million statistic does come from the IOM report but the 7,000 people killed is entirely unsourced. The actual stat alluded to - apparently from a 1998 Lancet paper via subsequent reports by the Institute of Medicine - is that each year 7,000 U.S. The Time article was way off the mark with regards to their statistic and juxtaposing that statistic with an unrelated source. In other news, I suppose I should stop assuming that Time articles legitimately source their statements. This case marks the first time that a physician has been found negligent for illegible handwriting.
Not the answer you're looking for?Browse other questions tagged medical-science or ask your own question. Did Professor McGonagall order that all Slytherin students leave when evacuating for the Battle of Hogwarts?
How can a shift manager discipline an employee when that employee is the owner's daughter? For medication errors, the patient safety goal is impacted because of the potential for patient death or serious harm.
The pharmacist selects the medication, measures the medication and then the medication is delivered to the nurse. As humans we are always susceptible to make errors, but understanding why we make them will help us design systems that decrease the chances of such errors to happen.
Eg: The nurse is distracted in her busy shift and gives a medication to her patient which was intended for another patient. The rule based errors or cognitive errors are very interesting and if you wish to learn more then refer to this brief article by Dr. Latent Errors :   Latent errors are accidents waiting to happen because of defects in the design of the system.
For the sake of simplicity, I have summarised the study results to one figure—10% (or one in every ten hospital admissions). Medical errors cause more accidental deaths in the USA than motor vehicle accidents, falls, drowning and plane crashes combined.
The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. It is a web-based application that lets nurses remotely perform medication management tasks away from the automated dispensing cabinet (ADC).
Nurses often feel rushed if others are waiting in line, which causes stress and can increase the potential for medication errors. Nurse interrupted: South Jersey Hospital uses technology to reduce disruptions, avoid errors.
Approximately 400,000 drug-related injuries occur each year in hospitals nationwide, according to a study from the Institute of Medicine.


Each year, five to 10 percent of patients get a preventable infection in the hospital, according to the Centers for Disease Control and Prevention.
Patients must be given full and adequate information about the nature of their ailment, the proposed course of treatment, possible alternative treatments, and risks and benefits. A misdiagnosis of cancer or other medical problem can have tragic consequences for a hospital patient. First, is this true - is there a statistically significant proportion of doctors who have handwriting which control groups would find hard to read? The report suggests that a typical hospital patient is subjected to at least one medication error a day. Another finds that among outpatient Medicare patients there occur 530,000 preventable ADEs each year.
It's a shocking statistic, and, according to a July 2006 report from the National Academies of Science's Institute of Medicine (IOM), preventable medication mistakes also injure more than 1.5 million Americans annually. But the direct answer to the question, "Does bad handwriting kill people?" is that yes, it can, if it is the underlying cause for an ADE that results in patient death. Even if the 7000 figure is high by a factor of 100, it answers the question in the affirmative.
Almost 300 different medications were mentioned in the reports, and 18.7% of the reports revealed that patients took multiple medications. It was then said that more people die from medical errors each year than from breast cancer or from motor vehicle accidents.
That is why it is now believed that errors are not made by defective people, but by defective systems. To combat this problem, hospitals are using computerized provider order entry (CPOE) systems.
Secondly, this article claims that because it is so bad, it can kill patients due to mistakes involving drug dosages, or incorrect surgery, or by other means. But nowhere in the report did I find an estimated death count for anything specifically targeting handwriting. Another error source I've experienced, even with electronic prescriptions, is that admin staff can mess up prescriptions, because they handle the re-ordering, and often insurance and formulations change, and patients relocate from one pharmacy to another. One or more controlled substances were involved in 40.3% of the events, and more than 25% of the reports mentioned a medication considered to be a high-alert medication. As if these figures were not staggering enough, a study was published recently in the Journal of Patient Safety that estimated the annual number of medical errors in U.S. Because one day the attending doesn’t have time to go over every detail about patient care and this unsupervised intern prescribes the wrong medication leading to active error. These programs eliminate transcription errors by requiring doctors to enter prescriptions into a computer electronically. To avert such tragedies, hospitals are requiring mandatory checklists like those used by airline pilots, even for routine procedures. When nurses and assistants exceed their authority by doing things outside of their area of expertise, patients are placed at risk. Employing strategies to prevent harm from patients taking their own medications can be prioritized by proactively assessing the risk associated with patients bringing in their own medications, developing a screening process for patients admitted to the facility who have a previous history of bringing in their own medications, and providing patient and family education upon admission to the facility about the facility’s policies in regard to patients’ use of their own medications.IntroductionThe medications prescribed for and administered to patients while they are hospitalized are typically provided by the hospital’s pharmacy department. However, there are times when it may be necessary for a patient to bring his or her own medications into the hospital.
With this medical errors stands as the third leading cause of death after myocardial infarction and cancer. The Centers for Medicare and Medicaid Services (CMMS) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), for example, have established effective protocols for making accurate diagnoses. For example, patients are often asked to bring their medications with them so that an accurate medication list can be generated for medication reconciliation. If the drug the patient needs is not on the hospital’s formulary and the hospital has no alternative therapy, the patients’ personal medications may be used to avoid an interruption in therapy.1 Some patients also may bring their medications from home to the hospital in hopes of saving money.
Many patients desire to self-medicate with their own medicines while in the hospital to ease anxiety over the loss of self-control of their care.2 Hospitals of all sizes face challenges in managing patients’ personal medications.
Larger institutions and government hospitals generally maintain larger inventories of medications and have closed formularies. Smaller community and rural hospitals may not have the space or funds to maintain a large inventory of medications and, therefore, may be more likely to allow patients to use their own medications.
A survey of directors of pharmacy at small hospitals (300 beds or less) found that a majority (90.9%) of the hospitals allowed patients to use their own medications while in the hospital. Before use or administration of a medication brought into the hospital by a patient, his or her family, or a licensed independent practitioner, the hospital identifies the medication and visually evaluates the medication’s integrity. The hospital informs the prescriber and patient if the medication brought into the hospital by patients, their families, or licensed independent practitioners is not permitted. Pennsylvania facilities have submitted a number of reports to the Pennsylvania Patient Safety Authority mentioning errors with the use of patients’ own medications, many indicating staff have found medications in a patient’s room that were brought from home without the hospital staff’s knowledge. There is scarce literature that addresses situations in which patients bring in their own medications, and a comprehensive search found no literature that discussed patients taking their own medications unbeknownst to the healthcare staff. Analysis of events reported to the Authority in which patients used their own medications has determined the most common types of events, patient populations involved, medications involved, and reasons why patients bring their medications to the hospital, as reported in Pennsylvania.Aggregate Analysis of Patients Bringing Their Own Medications into the Hospital While reviewing reports submitted to the Authority, analysts have the opportunity to further classify reports, using a “monitor code,” for future querying opportunities.
Analysts queried the Authority’s database for reports assigned the monitor code “PE1,” representing reports identified as errors involving patients using their own medications.
In addition, the event descriptions were queried for phrases such as “own meds” to identify reports that may involve patients taking their own mediations that were not assigned the “PE1” monitor code. The query yielded 879 medication error reports that had been submitted to the Authority from July 1, 2004, through January 31, 2011. Predominant Medication Error Event Types Associated with  Patients Taking Their Own Medications (n=746, 84.9% of total reports),  July 1, 2004, to January 31, 2011Events took place in 68 different care areas, as selected by facilities.
This does not include reports where no medications were mentioned (n = 114, 13%).Patient found unresponsive.
In 2010, two million people reported using prescription painkillers for nonmedical purposes for the first time within the last year—this equates to nearly 5,500 people per day.6 The unprecedented rise in overdose deaths in the United States parallels a 300% increase since 1999 in the sale of opioid painkillers.
Patient took the Soma and Valium by crushing the medications and self-administering via her gastrointestinal tube. The medications were discovered in the patient’s personal belongings along with a syringe and pill crusher.
In addition, empty bottles for [containing] Zanaflex®, Vicodin, and Darvocet® were found in the patient’s drawer. The patient’s parent brought in the patient’s home supply, and the nurse said the child could take that because the fever needed to be treated. The nurse went out to get an oral syringe, and when he came back to the room, the mother said she gave the child what “seemed like a lot of Tylenol.” The nurse asked how much, and the parent said 20 mL, which would be 640 mg.
The doctor was notified and labs were obtained, which showed an acetaminophen level of 30 and liver functions tests [serum glutamic oxaloacetic transaminase and serum glutamate pyruvate transaminase] increased significantly. More than 25% (n = 220) of the reports mentioned a medication that would be considered to be a high-alert medication in either the acute or ambulatory care settings.9,10 Of the 25 most commonly mentioned medications (see Table 2), 10 (40%) were high-alert medications. Most of these high-alert medications were opioids, but two medications, insulin and warfarin, were not. Forty percent (n = 28) of the 70 events involving high-alert medications resulted in patients being transferred to a higher level of care.  Table 2. Top 25 Medications Involved in Medication Errors  in Events in which Patients Took Their Own Medications  (n = 526, 59.8% of total reports) Reasons Patients Bring Their Own MedicationsAnalysts also reviewed event descriptions to determine if reporting facilities mentioned the reasons why patients felt the need to bring in and self-administer their own medications. Most of the reports submitted to the Authority involved situations in which the patients brought in their medications without informing facility staff and self-administered them.
However, at least 45 reports (5.1%) described errors that occurred in which organizations were intentionally using patients’ own medications.


A nurse gave an extra dose of fenofibrate [which was the patient’s own medication] instead of the thalidomide that was scheduled.
The patient’s thalidomide [also her home medication] was later found in another patient’s drawer. The next dose of fenofibrate was held and thalidomide was administered.Vytorin® [a combination tablet of ezetimibe 10 mg and simvastatin 20 mg] was ordered for the patient.
The pharmacy substituted Zetia® [ezetimibe] 10 mg and Zocor® [simvastatin] 20 mg to use for Vytorin, and that was printed on medication administration record. Patients were unaware that the directions for a particular medication were different in the hospital compared with at home. Patients were simply unaware that they should not take their own medications while in the hospital.The patient used the call bell and asked to speak to the med nurse. The medications administered included Zanaflex® 8 mg, Coumadin 5 mg, and docusate sodium 100 mg. She stated that her husband brought them in and that she took “everything, Dilantin®, phenobarbital, Colace®, all of them.” The doctor was notified and order was given to hold the medications. The lab alerted the staff that the patient had open bottles of medication on her bed with some of them spilled on the floor. When the patient was asked what she was doing, she stated she didn’t get enough medicine so she was taking her own.
When asked what she took, she stated that she took baby aspirin, heart pills, and Synthroid®. Over 12.6% (n = 111) of the reports indicated that patients self-administered their own medications because they were not completely satisfied with the care they were receiving. For example, patients stated that their pain was poorly controlled, that they were “tired of waiting” for their medication, or that their disease was not being adequately treated while in the hospital.The nurse discovered that the patient had medicated himself with insulin, indicating that he was concerned that staff did not medicate him in a timely manner. The patient had Humalog® insulin along with insulin syringes in his room, apparently from home.
The medication and syringes were removed from the patient’s room.A five-year-old patient was seizing for about six to seven minutes, with the doctor in the room.
The mother took the medication Diastat® [diazepam] out of a bag and gave [the patient] the medication, saying there was no time for a third party to retrieve [the medication]. The patient’s father was upset with the delay of medications reaching the nursing unit for his daughter. This medication was not approved by pharmacy.A patient was agitated about their elevated glucose readings for the past two checks. Adjustments were made to NovoLog® scale during the day shift; however, following the last elevated glucose reading, the patient expressed concerns about inadequate treatment.
Calls were made to the resident to explain the situation; patient was assured that a sliding scale order would be entered for the elevated reading, but no order was received. Risk Reduction Strategies Many institutions are confronted with managing the patient’s own medications that are brought in from home, and organizations can have procedures in place for the control and administration of these medications. Consider the strategies described in this section, which are based on a review of events submitted to the Authority and observations at the Institute for Safe Medication Practices:Proactively assess the risk associated with the use of patients’ own medications. If patients are asked to bring in medications only for reconciliation purposes, explain to the family why the medications were needed and encourage them to take the medications home. If the facility does not need to use a patient’s medications, explain to the patient and family the policy on bringing in prescription, over-the-counter, and herbal or homeopathic medications into the facility.Review medication administration records (MARs) to determine how the directions for patients’ own medications are expressed. Examples of circumstances allowing for personal medication use could include the following: The medication is not available on the hospital’s formulary, including those medications that are part of a restricted distribution system, compounded by an outside specialty pharmacy, investigational medications, and controlled substances.
The patient is on a continuous parenteral infusion of such medications as Flolan®, Remodulin®, or an insulin pump.1Develop an alternative plan to provide the medication to the patient if the pharmacy is unable to supply it before the next dose is due. For example, stating that if a patient’s home medication must be used, it should be administered by a nurse. Address the pharmacy’s role in this process, including the following: If the medications are not to be allowed for use, return them to the patient’s family or caregivers.
Ensure a process is in place to return the medications to the patient or family on discharge from the facility. Specify that the pharmacist is the health professional who will identify the medications, and include guidelines for another health professional to identify these medications if the pharmacist is unavailable. In one published account of a hospital’s assessment of medications that patients brought to the hospital, pharmacists were able to identify 95% of the medications, with 1 in 15 containers of these medications being mislabeled or unlabeled.11 Develop a process to ensure the proper labeling of any patient’s personal medications that are allowed for use in accordance with state regulations, making sure that the medications are identifiable, in good condition, and not expired.
Specific challenges to be addressed include the following:Changes in the frequency of administration.
For example, if a patient was taking their medication from home once daily but the directions have changed in the hospital to two times a day.The use of bar codes. If the organization uses bar coding at the point of care, the pharmacy will need to apply a bar code to each medication brought in by the patient for use within the facility.Before medications are sent to the nursing unit, place stickers or some other means of notification on containers for the medications that have been reviewed by a pharmacist. Use a documented tracking mechanism to communicate the use of patients’ personal medications, especially when patients bring in controlled substances or investigational medications. Develop a standardized approach in regard to the storage of patients’ own medications in the patient care area. In accordance with hospital policy, report any adverse events associated with the use of patients’ personal medications.
Ensure procedures are in place to return patients’ personal medications before discharge, and note the final disposition of the medications in the pharmacy records.ConclusionIn Pennsylvania, almost 900 medication errors have been reported from July 1, 2004, through January 31, 2011, involving patients taking their own medications while in healthcare facilities, many times unbeknownst to healthcare practitioners. One or more controlled substances were involved in over 40% of these events reported to the Authority, and more than 25% of these reports mentioned high-alert medications. Employing proactive strategies to address situations in which patients may bring in their own medications and implementing a screening method for patients admitted to the facility with a previous history of bringing in their own medications can be steps that are prioritized to prevent potential harm to patients.NotesNorstrom PE, Brown CM.
Results from the 2010 national survey on drug use and health: summary of national findings [online]. Drug Abuse Warning Network: selected tables of national estimates of drug-related emergency department visits. Patients do not realize that the directions for a particular medication are different in the hospital compared with at home.
Patients are not told that they should not take their own medications while in the hospital.
Which of the following statements reflect standards from the Joint Commission?The hospital defines when medications brought into the hospital by patients or their families cannot be administered. After the use or administration of a medication brought into the hospital by a patient, the hospital identifies the medication and visually evaluates the medication’s integrity.The hospital informs the prescriber and patient if the medication brought into the hospital by patients is permitted.
The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners.
Insulin and warfarin were the types of high-alert medications mentioned most often in the reports.While in the hospital, a patient self-administered atenolol 50 mg from her own supply. The patient brought in her medication from home because she thought that it was okay to take her high blood pressure medicine.
However, the patient’s attending physician had not ordered this medication for the patient.
What proactive strategies may help to prevent these types of errors?Develop a screening method for patients admitted to the facility who have a previous history of bringing in their own medications. Inform the patient and family upon admission to the facility about the facility’s policies in regard to patients’ use of their own medications. If the medication was brought in for reconciliation purposes, ask the patient’s family to take the medication home.



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