A Just Culture Approach to Managing Medication Errors.

Medication errors continue to be a concern of health care providers and the public, in particular how to prevent harm from medication mistakes. Many health care workers are afraid to report errors for fear of retribution including the loss of professional licensure and even imprisonment. Most health care workers are silent, instead of admitting their mistake and discussing it openly with peers. This can result in further patient harm if the system causing the mistake is not identified and fixed; thus self-denial may have a negative impact on patient care outcomes. As a result, pharmacy leaders, in collaboration with others, must put systems in place that serve to prevent medication errors while promoting a "Just Culture" way of managing performance and outcomes. This culture must exist across disciplines and departments. Pharmacy leaders need to understand how to classify behaviors associated with errors, set realistic expectations, instill values for staff, and promote accountability within the workplace. This article reviews the concept of Just Culture and provides ways that pharmacy directors can use this concept to manage the degree of error in patient-centered pharmacy services.

Improving medication administration safety in solid organ transplant patients through barcode-assisted medication administration.

Solid organ transplant recipients are prescribed a high number of medications, increasing the potential for medication errors. Barcode-assisted medication administration (BCMA) is technology that reduces medication administration errors. An observational study was conducted at an academic medical center solid organ transplant unit before and after BMCA implementation. Medication accuracy was determined and administration errors were categorized by type and therapeutic class of medication. A baseline medication administration error rate of 4.8% was observed with wrong dose errors representing 78% of the errors. During the post-BCMA period the medication administration error rate was reduced by 68% to 1.5% (P = .0001). Wrong dose errors were reduced by 67% (P = .001), and unauthorized medication administrations were reduced by 73%. Steroids were associated with the highest error rate. The results of this study suggest that routinely adopting BCMA has the potential to reduce medication administration errors in transplant patients.

Effect of barcode-assisted medication administration on emergency department medication errors.

OBJECTIVES: Barcode-assisted medication administration (BCMA) is technology with demonstrated benefit in reducing medication administration errors in hospitalized patients; however, it is not routinely used in emergency departments (EDs). EDs may benefit from BCMA, because ED medication administration is complex and error-prone. METHODS: A naïve observational study was conducted at an academic medical center implementing BCMA in the ED. The rate of medication administration errors was measured before and after implementing an integrated electronic medical record (EMR) with BCMA capacity. Errors were classified as wrong drug, wrong dose, wrong route of administration, or a medication administration with no physician order. The error type, severity of error, and medications associated with errors were also quantified. RESULTS: A total of 1,978 medication administrations were observed (996 pre-BCMA and 982 post-BCMA). The baseline medication administration error rate was 6.3%, with wrong dose errors representing 66.7% of observed errors. BCMA was associated with a reduction in the medication administration error rate to 1.2%, a relative rate reduction of 80.7% (p < 0.0001). Wrong dose errors decreased by 90.4% (p < 0.0001), and medication administrations with no physician order decreased by 72.4% (p = 0.057). Most errors discovered were of minor severity. Antihistamine medications were associated with the highest error rate. CONCLUSIONS: Implementing BCMA in the ED was associated with significant reductions in the medication administration error rate and specifically wrong dose errors. The results of this study suggest a benefit of BCMA on reducing medication administration errors in the ED.