Cause for Confusion

Do you know the causes of medication errors - and what to do to eliminate them? Ambiguous strength designation on labels or in packaging is a huge issue! Drug nomenclature creates look-alike or sound-alike products that can be confusing to health care providers and patients alike.

Consider This

Common causes for medication errors include:

• Improper transcription
• Incorrect dosage calculations
• Poorly trained personnel
• Incorrect abbreviations
• Labelling errors
• Excessive work load
• Exhaustion that causes lapses in performance

100% of these are preventable.

Medication errors are a reality; let’s prevent them in your hospital.

Three questions on the HCAHPS survey give us a fantastic excuse to be great about this issue.

• During this hospital stay, were you given any medication that you had not taken before?

• Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for?
• Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you understand?

In 2006, it was estimated that there are 1.5 million preventable medication errors each year, resulting in approximately 7,000 deaths. That number translates into one medication error per hospital every day, and that could be a low estimate. Pretty scary - what if one of those errors happened on your unit? How would you feel if that single error was caused by you?

The Take Away

Medication errors happen when we fail to consider the patient’s current medications; when we don’t adequately communicate about a new medication; and when we don’t understand a patient’s attitudes or fears about that medicine.

We cannot afford to make these mistakes.

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Medication Mayhem

Do you recall when the newborn twins of Dennis Quaid and Jennifer Buffington were in the news? It’s hard to forget a medication error so well publicized. The infants were supposed to receive the pediatric blood thinner Hep-Lock as treatment for an infection; instead, they got two doses of the adult version, Heparin - one thousand times more potent. Their blood was the consistency of water. Thankfully, when medical tests were done after the incident, there were no permanent signs of damage.

Consider This

The point, folks, is that it was a close call. It was a “never” event; it was preventable. The real question is: could it happen at your hospital? Make it your mission to master the skills of successful patient medication education.

How many of you have:

• had a close call with a medication error?
• been aware of injury or harm to a patient because of a medication error?
• challenged an order for a medication because it seemed incorrect as written?
• difficulty remembering why you were taking a drug?

Nurses are taught to be patient advocates, but sometimes when they get into the hospital, things change. Are your nurses empowered to challenge a physician about a prescription? Do they feel confident there will be no reprisals if they politely question the choice a physician has made? Have you instilled the what, how, and why of medication education in your nurses?

Do your nurses have the skills for working with patients who are confused about their meds, but won’t ask? Do they have the ability to discern and encourage patient compliance with medication regiments?

The Take Away

There’s no room for error when a difference in prescription or dosage could mean the difference between life and death.

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Bringing it All Together: The Clean Team

The more responsibility you give people, the more you empower them, the more you engage and coach them, the less they will interrupt you. The only way to have sustainable improvements (in any area) is to make the process self-sufficient. Staff engagement should be like a perpetual motion machine; you get things started, and then they continue under their own metaphorical steam.

Consider This

Leaders coach their “Clean Team:” the people who work for and with them. They engage employees in the cleanliness task, and encourage them to be fearless in speaking up when procedures need to change. Leaders need to empower employees to take the initiative and do what is necessary to keep a clean environment.

How is this done? With the Five-Step Coaching Model:

C             Communicate expectations. Clarify your hospital’s cleanliness objective: conquering HAI’s.

O             Opportunity for suggestions from staff. Gain staff buy-in by listening to their ideas for cleanliness improvement.

              A             Ask what actions staff are willing to take. Get them involved and applaud engagement.

C             Clear any roadblocks in their plan. Cheer their ideas.

H             Hear back the agreement and the HAI’s’ goals you’ve agreed upon. Happily follow up, and encourage staff in their efforts.

The ultimate high of being a coach or leading someone is when that someone reaches his or her potential. Both the person and the team of people he works with are rewarded. This is the great joy of leadership.

Foundations for Engagement – Do You Have an Effective Team to Lead Your HCAHPS/Cleanliness Domain?

We want to coach and bring about ownership. Engagement by all staff in the fight against HAI’s is not optional!

Service Excellence Council/Patient Experience Team: The mission is to provide focused leadership to engage everyone to improve the patient experience. We recommend a ratio of 60% management (people who have the time to provide leadership) and 40% frontline. Pick your brightest and your best. The purpose of this council or team is to provide representation of, and training to, the entire hospital organization.

If you want to be successful, there are three critical areas in which to direct your focus.

1.       Coordinate leadership and frontline education. Everybody has to know what to do - just because your staff attended a meeting doesn’t necessarily mean they know what to do. Try forming a Service Excellence Council (if you don’t have one already) to make sure the training takes place and remains in practice.

2.       Implement priority best practices. Focus on the ones that are highly correlated to becoming an employer and provider of choice.

3.       Monitor patient survey results and ensure continuous improvement. (What did we learn? What are we going to do better? What did we discover? What SOPs do we need to change?)

Lead by Example: Your staff have to see you leading the charge; they have to see you rolling up your sleeves. You cannot just say something and then not do it. You cannot simply distribute wonderfully written emails, or hold “town hall” meetings encouraging staff in word alone, because if they don’t see you walking the talk, they’re not going to do it either.

It is by example that people become involved.

The important thing is progress, not perfection. Make sure your leadership is open to the frontline’s involvement and initiative. If you respect their suggestions by honoring and implementing them, you will get the staff actively involved.

One final thought:

A toilet was overflowing onto the floor of a hospital, and a young staff member ran to the nearest office for help, which was the CEO’s office in Administration.

“What are we going to do?!” he cried.

The CEO led the young man to the supply closet, where the two of them got buckets and mops, and the CEO lead this staff member in cleaning up the situation.

The point is everyone is responsible for the cleanliness of the hospital. Everyone. If you set the standard, others will follow.

The Take Away

Improving and maintaining cleanliness is everyone’s responsibility. Informing and leading all staff in this process is the role of the Service Excellence Council – if you don’t have one, you should. Leading by example is the truest form of leadership.

“Be a master of the job before you. Be a student of the job above you. And be a coach of the job below you.”

– Adelfa Callejo

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