Identifying, Reporting, and Managing Medication Errors

SALT LAKE CITY—Although it’s important to strive for no chemotherapy-related medication errors, it’s just as important to have an organized system in place to identify, report, and manage these errors when they occur, according to a presentation at the annual meet ing of the Hematology/Oncology Pharmacy Association.

“We’ve made progress in medication errors both from understanding their epidemiology in the past 15 years and how we can mitigate them through technology, workflow, and system changes,” said Sylvia Bartel, RPh, MHP, from the Dana-Farber Cancer Institute in Boston, Massachusetts.

Still, errors occur for multiple reasons, including understaffing, a lack of knowledge, or system failures—and may include issues with order writing and communication, dose miscalculations, incorrect drug administration, or poor distribution.

“Our systems are really complicated, and sometimes we have mental lapses. We all work in very busy environments, and although we try to have a quiet space for pharmacists to process orders or for physicians to write them, in reality that is often not the case,” said Bartel. “We learn from this by looking at how our systems fail and seeing where we have redundancies and where we don’t have redundancies but should.”

Because errors often start with the order, it’s imperative that providers keep everything clear, such as the drug, dose, and schedule. Dose miscalculations are also common, often because of complicated formulas for determining body weight, and drug shortages can lead to the staff being unfamiliar with the substitute medication.

“Chemo agents, by nature of what they are, can lend themselves to medication errors, particularly adverse drug reactions,” said Bartel. “We expect patients to be sick, to have fatigue and nausea, but is that really an expected adverse reaction or is it due to an error?”

Although the person who discovers an error is supposed to call a specified phone number, put it into the computer system, or alert someone face to face, Bartel said that only 2% to 5% of errors are discovered through “spontaneous reporting.” Instead, she suggests taking a hard look periodically at a particular process and then gathering data on it.

“Look at orders, go back to the cart, look at the workflow process. When errors get reported, we really want to make sure we look at how it happened on multiple levels so that we get at the root cause,” she said.

At Dana-Farber, they strive to make sure their error reporting system is anonymous, easy to use, and includes a severity rating scale to assess potential harm. The data then are used to develop process improvements. In addition, an oncology-specific self-assessment tool from the Institute of Safe Medication Practices is expected to be released this fall.

When it comes to managing an error, disclosing its occurrence to the patient should be the first step, followed by giving support to staff members who might be upset and taking it personally. Bartel also suggested adopting a “Just Culture” approach. “Man - agers need to help their staff look at system changes as opposed to having a punitive environment to catalog in a performance review how many errors they were involved in. The individual is accountable for what is under their control but it’s part of the broader context of the system.”

Overall, Bartel said that it’s important to create a work environment that rewards error reporting, values safety and continuous learning, and encourages managers and staff to have open discussions about potential risks and how best to avoid them. “It’s just a new way of thinking.”