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Medication error prevention: Defeating work-arounds

Quality improvement

After reading this article, you will be able to:

  • Identify common medication errors
  • Explain examples of potential medication errors
  • Discuss the role of vaccinations and work-arounds in logging medication errors

In an effort to eliminate medication errors, Central Vermont Medical Center (CVMC) in Barre has reexamined its process of charting medication errors and identifying work-arounds and other potential areas where the process can be derailed.

“We have a documentation system, which includes an adverse event report,” says Barb Sharp, RN, MS, CPHQ, CPHRM, quality manager at CVMC. “The electronic form is completed by the medical area that discovered the error.”

This report is structured to show how and when the physician was notified of an error and tracks the stage in the process where the error first occurred.

A description of the event is submitted electronically and goes to the chair of the medication use committee as well as to the pharmacy director and quality manager.

“I, as quality manager, look at all of these and conduct follow-up,” says Sharp.

For example, a patient might receive 20 mg of methadone when he or she was supposed to receive 10 mg. Sharp tracks down the original occurrence of such an error and asks, “Do we have a problem here with diversion, a problem with not being able to read the dosage … it may be a case in which the nurse simply read the dose wrong.”

Once per month, the medication management committee meets, during which time the group has an opportunity to review the logs for the automated medication dispensing system (the facility uses Pyxis MedStations). “We’ve found it useful to look at the Pyxis override logs,” says Sharp. “We started reviewing those at every meeting, and it’s interesting.”

In a business or medical culture, you have to look at process problems, she says.

“You have to acknowledge that sometimes people deliberately ignore policies with work-arounds,” says Sharp. “But if you see someone who is consistently overriding the system, it gives you an opportunity to go to that nurse or pharmacist and ask, ‘What’s the problem here?’ ”

This can be a learning situation for the organization and staff members. Are they using the work-around because the process itself is not working, or do staff members assume they know better and ignore the system’s checks?

Talking to staff members about their use of work-arounds can be invaluable.

Missed doses

CVMC primarily uses an electronic medical record (EMR), but still has certain units using manual administration records (MAR).

“We don’t see a missed dose very often on the units using the EMR,” says Sharp. “The majority of errors occur with the MAR—patients get so many medications these days it’s easy to miss. With the EMR, it won’t let you move on until you’ve satisfied [the dose requirements].”

Still, there are possibilities for errors even with the EMR. Sharp offers another hypothetical situation: An order is written after the pharmacy is closed involving a medication that is not available for night manager access. In this case, the dose could be missed until the pharmacy opens the next morning.

“The EMR couldn’t help that,” says Sharp.


Missed doses also come into play when dealing with flu and pneumonia vaccinations. In certain cases, a nurse work-around may be required.

“If the patient has refused the vaccine or they aren’t eligible for it, there would have to be a nurse override or nurse hold to make that happen,” says Sharp.

In some ways, the process is more challenging than it should be, she says. The facility has a flu vaccine team, and the vaccinations are on the standing orders.

“For whatever reason, if the patient didn’t need the medication, it comes up on the EMR as part of the standing orders,” says Sharp.

The team brought in the hospital’s information systems (IS) department to avoid work-arounds and allow users to identify when the patient has refused the vaccine or determine other reasons why the dose is not given.

“You’ve got to be sure [the process] makes sense,” says Sharp. “One of the easiest things for a clinician to do, if a process is cumbersome, is find a work-around.”

Upon finding an issue with the EMR or dispensing machines, a quality improvement person must involve the end users to identify the cause of the problem.

One big problem CVMC discovered is the use of work-arounds surrounding core measures and influenza and pneumococcal vaccinations.

“We’ve found by looking at the Pyxis logs that there are ways that are legitimate in finding that these vaccinations don’t need to be given,” says Sharp. “We’re trying to standardize the process, make sure everyone is educated.”

CVMC is examining Pyxis logs, has a nurse vaccination team, and includes pharmacy and IS in addressing this ongoing issue.

“We’ve identified these work-arounds as part of the vaccination issue, but it’s bigger than that, and it has helped us,” says Sharp. “The abstractors have identified the problem and sat down with a multidisciplinary team to address the issue.”

The process has also helped resolve other issues, including vaccinations and scheduling on the MAR, which sets vaccinations for 2 p.m.

“If you’ve got a patient going home in the morning, those doses can be missed,” says Sharp.

To fix this, an alert has been implemented as part of the discharge checklist that requires nurses to verify the status of patients’ vaccinations.

“What I’m excited about is the fact we’ve got a medication systems team and a performance improvement team with two very different purposes who have found the same issues and are working together to improve the whole system,” says Sharp.

Medication reconciliation is the next step in process improvement at CVMC.

“Our process is essentially paper-based currently,” says Sharp. “I’d like to see that go completely electronic.”

The facility has a hospitalist program, and the majority of inpatients go through the program. Hospitalists handwrite the medication reconciliation document, and the nurse completes the sheet and goes over it with the patient.

“This would be so much easier to read and faster as an electronic process,” says Sharp.


Adapted from Briefings on The Joint Commission, August 2009, HCPro, Inc.

What are the most common medication errors?

  • Wrong drug
  • Wrong dose
  • Wrong route
  • Wrong frequency