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Medication Safety and Communication Skills

Types of Errors: Possible Causes and Potential Solutions

Communication with Health Care Providers

  • Over the phone

    • Distractions and noise that interfere with the transactions

    • Heavy accents as well as other language barriers

    • Obscure terminology or big terms

    • Similar medications when spoken

    • Numbers that sound alike

  • Handwritten communication

    • Poor handwriting

    • Names that look alike

    • Wrong name in the drop-down menu

    • Decimals either in the wrong spot or are unclear

    • Unclear abbreviations

    • Alert fatigue

  • How to Compensate

    • Get rid of distractions

    • Try changing the lighting

    • Provide feedback and open communication with other healthcare professionals

    • Take advantage of barcoding

    • For sound-alikes, add accentuates on certain syllables

    • For verbal order, repeat it back to verify

Communication with Patients

  • Common problems

    • Can’t comprehend

      • Accent

      • Terminology

    • Hearing or visual impairments: cannot understand written information

    • Not correctly identifying the patient

    • Patients not speaking up with questions

  • How to fix

    • Allow the patients to paraphrase what you just told them

    • Give them a written copy of the information so they can refer to it later

    • Allow them to ask questions

    • Take advantage of your resources

General Strategies to Enhance Patient Safety

Reporting Errors

  • To error is to be human: creating a safe environment where errors are nonpunitive is essential to have an open and honest atmosphere

  • The purpose of reporting errors is not to get someone in trouble but to learn from it and possibly better the safety precautions

  • The majority of errors are caused by the system and not the person

Organized Strategies to Minimize Errors

  • Failure Mode and Effects Analysis and Root Cause Analysis are two ways to identify and prevent possible errors

    • FMEA identifies both sources and consequences of failures based on past events

    • RCA focuses on specific root causes of error

      • It asks why not how

  • These systems cannot prevent 100% of errors

  • They can only minimize how often and how severe they are

When Errors Occur

Initial Discovery

  • Avoidance: denial that the error happened and refusal to help fix it

  • Blame: “It was someone else’s fault they messed up”

  • Rationalizing: it wasn’t that important: it is not a big deal

  • Assuming someone else will catch their mistake

Initial Contact with Patient

  • When meeting try to go somewhere private

  • Explain what happened and the short-term consequence

  • Tell them how the problem is being resolved

  • Assure them they have not been forgotten about

Further Contact

  • Once the patient has a clear idea that an error has occurred and how it is being resolved, you may want to provide additional insights into why it occurred.

  • Some patients might want to know how it occurred and what steps you are going to implement to prevent future occurrences.

  • Be honest and upfront with the patient about the long-term consequences of the error. They may be interested to learn how they will be compensated for their inconvenience or injury

  • You should make sure that you do not rush through the experience and allow patients time to ask questions and express their feelings.

  • This feedback will help you determine whether you need to conclude the interaction or continue to address the patient's remaining concerns.

  • A sincere closing statement, such as "This rarely happens, but it happened with your prescription and I want to resolve it," may put the error in perspective.

Contacting Other Health Care Providers

  • Be the one who controls the information

  • Revealing errors to other providers is helpful for their quality assurance efforts as well.

MJ

Medication Safety and Communication Skills

Types of Errors: Possible Causes and Potential Solutions

Communication with Health Care Providers

  • Over the phone

    • Distractions and noise that interfere with the transactions

    • Heavy accents as well as other language barriers

    • Obscure terminology or big terms

    • Similar medications when spoken

    • Numbers that sound alike

  • Handwritten communication

    • Poor handwriting

    • Names that look alike

    • Wrong name in the drop-down menu

    • Decimals either in the wrong spot or are unclear

    • Unclear abbreviations

    • Alert fatigue

  • How to Compensate

    • Get rid of distractions

    • Try changing the lighting

    • Provide feedback and open communication with other healthcare professionals

    • Take advantage of barcoding

    • For sound-alikes, add accentuates on certain syllables

    • For verbal order, repeat it back to verify

Communication with Patients

  • Common problems

    • Can’t comprehend

      • Accent

      • Terminology

    • Hearing or visual impairments: cannot understand written information

    • Not correctly identifying the patient

    • Patients not speaking up with questions

  • How to fix

    • Allow the patients to paraphrase what you just told them

    • Give them a written copy of the information so they can refer to it later

    • Allow them to ask questions

    • Take advantage of your resources

General Strategies to Enhance Patient Safety

Reporting Errors

  • To error is to be human: creating a safe environment where errors are nonpunitive is essential to have an open and honest atmosphere

  • The purpose of reporting errors is not to get someone in trouble but to learn from it and possibly better the safety precautions

  • The majority of errors are caused by the system and not the person

Organized Strategies to Minimize Errors

  • Failure Mode and Effects Analysis and Root Cause Analysis are two ways to identify and prevent possible errors

    • FMEA identifies both sources and consequences of failures based on past events

    • RCA focuses on specific root causes of error

      • It asks why not how

  • These systems cannot prevent 100% of errors

  • They can only minimize how often and how severe they are

When Errors Occur

Initial Discovery

  • Avoidance: denial that the error happened and refusal to help fix it

  • Blame: “It was someone else’s fault they messed up”

  • Rationalizing: it wasn’t that important: it is not a big deal

  • Assuming someone else will catch their mistake

Initial Contact with Patient

  • When meeting try to go somewhere private

  • Explain what happened and the short-term consequence

  • Tell them how the problem is being resolved

  • Assure them they have not been forgotten about

Further Contact

  • Once the patient has a clear idea that an error has occurred and how it is being resolved, you may want to provide additional insights into why it occurred.

  • Some patients might want to know how it occurred and what steps you are going to implement to prevent future occurrences.

  • Be honest and upfront with the patient about the long-term consequences of the error. They may be interested to learn how they will be compensated for their inconvenience or injury

  • You should make sure that you do not rush through the experience and allow patients time to ask questions and express their feelings.

  • This feedback will help you determine whether you need to conclude the interaction or continue to address the patient's remaining concerns.

  • A sincere closing statement, such as "This rarely happens, but it happened with your prescription and I want to resolve it," may put the error in perspective.

Contacting Other Health Care Providers

  • Be the one who controls the information

  • Revealing errors to other providers is helpful for their quality assurance efforts as well.

robot