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.

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