Patient Safety,
Medication Errors, and
“At-risk” Behaviors
Christine M. Wilson
Advanced Concepts of Pharmacology
Viterbo University
Something to Think About
Patient
Safety
should not
be a priority
in
healthcare.
Medication Error
 Any preventable event that may
cause or lead to inappropriate
medication use or patient harm,
while the medication is in the
control of the healthcare
professional, patient, or
consumer

NCC MERP, as cited in Lehne, 2004
Medication Errors Impact
Patient Safety
Missed doses
Wrong time of administration
I.V. rate too fast
Wrong concentration or dose
delivered I.V.
 Wrong route of administration
 Missed or mistaken provider orders




Nursing Actions Impact
Patient Safety
 Mis-identification of patient; wrong
medication delivered
 Documentation of medications before
giving to patient
 No documentation of changing patient
conditions
 Lack of attentiveness
 Inappropriate judgment
Remember When ?
 Novice nurse behaviors and actions
 Nervous and careful with medication
administration
 Provides undivided attention to task
 Prepares one medication at a time
 Seeks information about unfamiliar meds
 Checks patient allergies, weight, lab values
 Has another double check medications
 Provides education to patient about meds
After Gaining Experience ?
 Expert nurse behaviors and actions
 Prepares IV mixtures, not waiting for pharmacy
to prepare
 Administers medications before pharmacy
reviews orders
 “Borrows” another patient’s meds, to allow quick
administration
 Does not label self-prepared syringes of meds
 May not take med record to bedside for prns
 Has unauthorized med “stashes” on unit
At-risk Behaviors
 Intentional and unsafe practice
habits, learned through experience
 Healthcare providers, insurers,
pharmaceutical industry, medical device
vendors
 Engage in at-risk behavior because
rewards are often more immediate and
positive than the potential for patient
harm

ISMP Medication Safety Alert, 2004
Sources for At-Risk Behaviors
 System-based
 Unnecessary process complexity
 Patient medication in multiple storage areas
 Nurse may move meds to more readily
accessible area
 Problems with technology
 Repeated waiting for computer terminal
access
 Physician may resort to verbal orders when
prescribing
 Pharmacist may skip checking lab values
Sources for At-Risk Behaviors
 Organizational culture with high tolerance
for at-risk behaviors
 Staff believes more positive rewards than
negative rewards for at-risk behavior
 “Saves” time now; chance of patient harm
viewed as remote and unlikely
 Staff believes more negative rewards than
positive rewards for corresponding safe behavior
 Labeled as “slow employee”, rather than
“efficient”
Areas Involving Potential
At-risk Behaviors
Patient information
Drug information
Communication
Labeling,
packaging
 Drug stock,
storage,
distribution
 Patient education




 Staff education
 Technology
 Environment/
staffing patterns
 Quality/culture
 Double checks
 Teamwork
Environment/Staffing
 More concern with cost
of medication units,
rather than safety
 Managing multiple
priorities while
carrying out complex
processes
 Failure to adequately
supervise/orient staff
 Inadequate staffing
based on patient
acuity
Quality/Culture
 Sacrificing safety for
timeliness
 Failure to report and
share med error
information
 Organizational culture
inspires secrecy
instead of openness
 Finger-pointing rather
than system change
Double Check/Teamwork
 Failure to perform
independent double
check thoroughly
 Failure to ask
colleague to double
check medication
 Reluctance to consult
colleagues for help
 Unresponsive to
colleague’s request
Consider . . .
 Should patient safety be a priority in
healthcare?
 “Priority” implies an order in a list that
can be altered according to
circumstances
 Could this “order” be based on:
 Demands of the shift or day?
 Focus of expedience, productivity,
efficiency, or cost effectiveness?
Case Example
You have had a busy shift and it is now
1400; a new admission has been
assigned to you and the patient will
arrive soon. Due to family obligations,
you must leave the unit at exactly
1500. The 1400 IV medication for one
of your other patients is “missing”, so
you call the pharmacy.
Discussion
Under these circumstances, how would
you react to:
 Pharmacist takes time to fully investigate
where the missing medication is located
 Pharmacist immediately mixes another
dose and sends it to you
Priorities?
Which action offers more positive
reinforcement?
Case Example
It is 0800 and you are engaged in a
hectic patient assignment. The
physician is writing orders to transfer
one of your patients to another nursing
unit. The hospital policy states that
medication administration records will
be reviewed by the physician during the
transfer process to avoid unintentional
discontinuation of medications.
Discussion
Under these circumstances, how would
you react if:
 You are using the medication
administration record when the physician
wants it
 The physician elects to not check the
medication administration record prior to
writing orders
Priorities?
Which action offers more positive
reinforcement?
Patient Safety as a Value
 Link uncompromised patient safety to
every healthcare activity
 Emphasize specific behaviors which
contribute to patient safety
 When at-risk behaviors identified:
 Do not use disciplinary actions
 Do uncover reasons for using them
 Conscious risk-taking not involved in all
medication errors; prompt for answers
References
 Institute for Safe Medication Practices. (2004, October
7). ISMP medication safety alert! Retrieved April 17,
2005, from
http://www.ismp.org/PDF/At_Risk_behaviors.pdf
 Institute for Safe Medication Practices. (2004, October
7). Reducing "at-risk” behaviors. Retrieved April 17,
2005, from
http://www.ismp.org/MSAarticles/ReducingPrint.htm
 Institute for Safe Medication Practices. (2004,
September 23). Why we engage in "at-risk
behaviors". Retrieved April 17, 2005, from
http://www.ismp.org/MSAarticles/PatientPrint.htm
 Lehne, R. A. (2004). Adverse drug reactions and
medication errors. Pharmacology for Nursing Care
(5th ed., pp. 62-71). St. Louis, MO: Saunders.