Abstract:
Despite an established incident reporting system, Medcare Hospital employees were simply not recording medication errors in 2013. In fact, only two medication errors were documented between January and September of that year. Either staff was being incredibly diligent in avoiding errors, or a lack of proper data collection meant the hospital’s quality management department (QMD) was not receiving the full picture, and thus patient safety improvement efforts were not being fully supported. This critical question needed to be answered.
Errors involving patient medication can happen in various ways, many creating potentially life-threatening scenarios. If a hospital employee dispenses the wrong medication due to an illegibly written order, or if a nurse gives a medication to the wrong patient, the ramifications can be deadly. Not only does the patient suffer, but the hospital could face legal action and the staff member who made the error could have his/her career derailed as a result. Therefore, when Medcare’s QMD staff learned only two medication errors were reported during the first nine months of 2013—a new low mark for the department after reported errors had been decreasing in recent years—management determined it imperative to identify what barriers or struggles existed for employees to reporting errors through the existing system, and what, if any, changes needed to be made. Given these circumstances, an improvement project focused on medication error reporting was a good fit for the QMD performance improvement program. The program is based on data collection and statistical analysis to evaluate performance, measure outcomes, identify improvement opportunities, and determine priorities. Medcare’s performance improvement activities are prioritized in collaboration with the facility’s administrative and clinical leadership. In this case, hospital leaders understood unreported errors could compromise patient safety and inhibit efforts to improve safety results. Error detection is the first crucial step in the opinion of Shaheena Surani, Assistant Quality Coordinator at Medcare Hospital.
