Earlier this year, a study and analysis by industry experts at Johns Hopkins revealed that medical errors are the third-leading cause of death in the United States, killing more than 250,000 patients per year. The study has been questioned by some, and it did not detail exactly what types of errors resulted in death. However, we have seen studies that show medication errors affect 1.5 million Americans, leading to more than 7,000 deaths annually, reported in “Preventing Medication Errors,” by the Institute of Medicine of the National Academies in 2006. Pretty staggering numbers when you consider that medication errors are largely preventable.
As nurses, we are in an optimal position to help reduce and even prevent medication mistakes. We spend more time with patients than any other member of the care team, so presumably we have more opportunity to identify red flags and proactively catch mistakes before they happen. However, in reality this is easier said than done.
Occurring largely during a transition of care such as discharge, medication errors can send patients back to the hospital, or in extreme cases, cause death. In fact, research shows that 20 percent of all patients discharged experience some sort of adverse event within five weeks, with two-thirds of those events related to medication, as reported to Congress by the Medicare Payment Advisory Commission in 2007. Why do medication reconciliation mistakes happen more frequently during transition events, and how can we as nurses prevent them from happening?
In spite of all the standardized processes and checklists supporting safe medication practices, I believe the issue is rooted in the normal anxiety and disruption that surrounds a transition of care. Anxiety on behalf of the nurse who is focused on avoiding mistakes, anxiety on behalf of the patient who is beginning a new phase outside of the safety and security of the hospital, and the overall disruption of the whole process. At any transition point, but especially at discharge, medication reconciliation is one part of a much larger picture. Nurses are responsible for managing this big picture, and more likely than not also managing multiple patients at the same time, all with differing needs. By providing nurses with the tools and technology that help them better recognize the potential for a medication error before the point of need, anxiety on all sides can be controlled and medication-related mistakes can be avoided.
I recently had the privilege of conducting focus group research in partnership with a company that for more than 30 years has served as the primary source of medication learning for pharmacists. This company was interested in finding out whether there was a need for nurse medication learning. My experience told me that there would be a need, but after digging into it, I discovered it was much more profound than I had anticipated. Our research showed that nurses were familiar with medication databases, but didn’t know there were resources that could tell them what they need to know before knowing it was needed. From this research, TRC Healthcare created a new medication learning solution, “Nurse’s Letter,” which includes evidence-based, unbiased, clear-cut and current drug therapy and medication management recommendations.
Providing information that can help identify exactly where there is a potential for error, medication learning tools for nurses also inspire confidence among the nursing staff and allows them to communicate in a more consistent and effective manner with prescribers, patients and their at-home caregivers. Both of which can naturally ease patient anxiety by enhancing the understanding of their medication treatment plan. It also helps patients feel more comfortable about their transition away from the hospital.
Hospitals that not only make these types of resources available but also make them part of the core lifelong learning process for the nursing team can prepare their staff to do a better job with medication management overall. This is especially true in organizations that recognize the most effective solutions come from the establishment of a partnership with the nursing team. Actively seeking input and understanding what nurses need to do their jobs effectively goes a long way to ensuring that whatever solution is selected will be used, and used effectively.
The biggest obstacle to effective medication learning is time. RNs manage multiple patients and multiple responsibilities on a daily basis, leaving very little room for anything else. Understanding when it makes sense to take time for learning and education is critical. Medication learning tools like Nurse’s Letter are designed to address these challenges and provide control over the overwhelming amount of available medication information. Curated by practicing medical professionals that include pharmacists and nurses, only the most relevant and up-to-date information is provided. This allows nurses who are already stretched for time to quickly pinpoint the information that is relevant to their practice.
As nurses, it’s our job to put patients first. We serve every patient with compassion and are in a position to directly impact quality and outcomes. Forward-thinking organizations don’t just recognize the value in medication learning, they recognize the value in empowering their nursing staff to make the right care decisions for patients. Medication errors are preventable, and nurses are in an optimal position to make a difference. The right tools and support enable nurses to better identify potential reconciliation issues, helping prevent errors and improve overall quality of medication therapy for patients.
— Kathy Malloch is president of KMLS LLC and a member of the American Nurses Foundation Board of Trustees.