Learning From Medication Errors:
Promoting a Culture of Safety and Support in Your Practice
Laura M. Cascella, MA
Working to eliminate preventable medication errors is a worthwhile goal for any healthcare
practice. However, in the fast-paced healthcare environment, with the numerous demands on
doctors and the large volume of available medications, the possibility of eliminating all errors is
unlikely. Thus, being prepared to handle errors and learn from them is a priority in creating a
culture of safety that is continually evolving and improving.
Just as healthcare practices should have processes and procedures in place to guide medication
safety, so too should they have adequate systems and processes for identifying, addressing,
disclosing, and reporting medication errors, adverse drug events, and near misses — as well as
ample opportunities for staff to learn from errors that occur both within the practice and in the
healthcare community at large.
Identifying
Root cause analysis often is the first step in determining how and why a medication error occurred.
The best way to initiate the analysis might be to examine the healthcare practice’s current policies
and protocols. These guidelines should clearly define the appropriate actions for evaluating the
events surrounding an error or near miss, such as saving materials or supplies that might help
determine the cause of an error.
In addition, staff members who are involved in a medication mishap should help review and assess
the incident and the circumstances involved, and management should seek their input on strategies
for improving system- or process-related issues that may have contributed to the error.
The Institute for Safe Medication Practices (ISMP) also suggests that, when attempting to identify
errors and their causes, healthcare practices might find it helpful to seek external feedback from
local pharmacies and hospitals about any possible errors originating in the practice. This feedback
can provide valuable information that will help improve internal processes. 1
Addressing
Following an analysis of the root cause of a medication error or near miss, designated staff
members should recommend and implement any changes or additional steps to the practice’s
procedures for prescribing, administering, storing, or dispensing medications.
Additionally, the practice should determine a viable way to communicate critical information about
errors and near misses with staff, whether individually (e.g., in an alert sent to staff mailboxes) or as
a group (e.g., in a staff meeting). Timely and proactive communication will encourage staff
members to participate in medication safety initiatives and feel comfortable making
recommendations and asking questions.
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