R E V I E W S & A N A LY S E S Wrong-Patient Medication Errors: An Analysis of Event Reports in Pennsylvania and Strategies for Prevention Annie Yang, PharmD, BCPS INTRODUCTION Patient Safety Analyst Patient misidentification has been a long-standing problem that has permeated all Matthew Grissinger, RPh, FISMP, FASCP Manager, Medication Safety Analysis aspects of healthcare and led to errors ranging from wrong-site surgeries to discharg- Pennsylvania Patient Safety Authority ing infants to the wrong families to ordering incompatible blood. From 2006 to 2007, the United Kingdom National Patient Safety Agency (NPSA) received 24,382 reports of patients being mismatched to their care.1 The Joint Commission, which has been tracking these errors since 1996, reviewed 152 sentinel events related to wrong-patient, ABSTRACT wrong-site, and wrong-procedure events in 2011 alone.2 Because of the prevalence of During the period of July 1, 2011, patient misidentification, some organizations have offered various risk reduction strate- through December 31, 2011, 813 gies. The Joint Commission targets improving the accuracy of patient identification as wrong-patient medication errors were a National Patient Safety Goal (NPSG).3 Internationally, NPSA has recommended the reported to the Pennsylvania Patient use and the standardization of patient identity wristbands in the United Kingdom.1 Safety Authority. These reports were The World Health Organization (WHO) has also proposed strategies to prevent patient analyzed to classify the events by node, misidentification.4 Despite these and other efforts, few studies have been performed related processes, possible causes, and that have analyzed wrong-patient medication errors in particular. More importantly, contributing factors and to detect trends there have been few recommendations on the specific safeguards that should be imple- and noteworthy cases. Errors most often mented throughout the medication-use process to prevent such errors. occurred during transcribing (38.3%, Wrong-patient medication errors can be thought of as both an unordered-drug error n = 311) and administration (43.4%, for the patient who received the dose and an omission error for the patient for whom n = 353) and least during dispensing the dose was intended.5 Although wrong-patient errors are often erroneously consid- (5.2%, n = 42). Anti-infectives, opioids, ered as administration of one patient’s medications to another by a nurse, reports and anticoagulants were the most submitted to the Institute for Safe Medication Practices (ISMP) have shown that common types of medications associ- wrong-patient errors can originate from any phase in the medication-use process.6 This ated with wrong-patient events. While analysis serves to uniquely review a large set of medication error events reported by multiple factors may have contributed Pennsylvania healthcare facilities to the Pennsylvania Patient Safety Authority in order to each event, the most common were to understand the various ways wrong-patient medication errors occur in each node of two patients being prescribed the same the medication-use process, identify trends and contributing factors, and provide risk medication, improper verification of reduction strategies to prevent these events from occurring. patient identification, and similar room numbers. Important risk reduction strate- METHODOLOGY gies include ensuring proper storage of medications and patient-specific docu- Due to the volume of reports submitted in a calendar year, medication error event ments, utilizing healthcare technology reports from July 1, 2011, through December 31, 2011, that were categorized as “wrong fully, limiting verbal orders, and improv- patient” were queried from the Authority’s Pennsylvania Patient Safety Reporting Sys- ing patient verification throughout the tem (PA-PSRS) database. All fields of the event reports, including harm score and care medication-use process. (Pa Patient Saf area, were self-reported, but the medication name fields were adjusted during analysis Advis 2013 Jun;10[2]:41-9.) if information on the medication involved in the error had been available in the event description. Medication name fields that were left blank or did not contain names of Corresponding Author Matthew Grissinger approved medications and were not able to be adjusted based on information in the event descriptions were categorized as “unknown.” The medications were then cate- gorized as being high-alert or not per ISMP’s List of High-Alert Medications.7 The event description fields were analyzed in detail in order to classify each event by node, related processes, and possible causes and contributing factors. Various trends were quantified using descriptive statistics. AGGREGATE ANALYSIS During the aforementioned reporting period, the Authority received 826 distinct medi- cation error event reports from Pennsylvania healthcare facilities that were categorized as wrong-patient events. However, based on the event descriptions, 13 reports (1.6% of total reports) did not actually involve wrong-patient errors and were excluded from Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 41 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S the analysis. The remaining 813 reports Figure. Wrong-Patient Errors by Node, as Reported to the Pennsylvania Patient represent errors that occurred across Safety Authority, July 2011 to December 2011 the continuum of the medication-use 9 42 process (from prescribing to administra- (1.1%) (5.2%) tion and monitoring of medications), involved a wide range of medications, and occurred on various patient care units and 98 departments. (12.1%) Prescribing The errors reported occurred during all Transcribing nodes of the medication-use process (see Figure). The reported errors occurred Administration most often during transcribing (38.3%, 353 (43.4%) 311 n = 311) and administration (43.4%, (38.3%) Dispensing n = 353) and least during dispensing (5.2%, n = 42). Unknown While there were many different medi- MS13090 cations involved, the most prevalent medications were similar to those reported in previous analyses of events reported to the Authority.8,9 Insulin (4.3%, n = 35), Twenty-five reports (3.1%) involved pediat- actual medication administration (81.0%, heparin (2.6%, n = 21), and vancomy- ric patients. It is unclear, however, whether n = 286), 15.6% (n = 55) occurred during cin (2.5%, n = 20) were the three most the locations noted in the event reports medication procurement, and 3.4% (n = common medications involved in wrong- represent where the errors originated or 12) occurred during monitoring. Medi- patient errors. Opioids were mentioned in where the errors were discovered. cation procurement consists of a nurse 7.5% (n = 61) of event reports, and anti- Despite the variety of medication errors obtaining the wrong medication from vari- coagulants, such as warfarin and alteplase, involving the wrong patient, few resulted ous medication storage areas (see Table 1). were reported in 6.0% (n = 49) of event in patient harm. Reporters self-categorized For example, multiple reports described reports. Almost 13% (n = 104) of reports the events by harm score, which is adapted a nurse selecting the wrong patient from listed anti-infective medications as being from the National Coordinating Council the automated dispensing cabinet (ADC) involved in the event. A similar number for Medication Error Reporting and screen when retrieving medications. of reports (12.7%, n = 103) involved Prevention (NCC MERP) Index for Cat- Monitoring is defined as patient assess- more than one medication, and many egorizing Medication Errors.11 Only three ment activities that occur before or after reports did not specify which medication reports (0.4%) were categorized with harm administration of medications. The most was involved in the wrong-patient error score E, and one report (0.1%) was catego- prevalent monitoring error was related (16.6%, n = 135). Of the reports involving rized with harm score F. A majority of the to laboratory test values (83.3%; n = 10), a known single medication, almost 30% reports (84.1%, n = 684) were categorized such as blood glucose results. (n = 169) were associated with high-alert as harm score C or less. Many factors, and often more than one medications. This finding is similar to one factor per event, contributed to patients from a previous analysis in which one- receiving other patients’ medications FOCUSED EVENT ANALYSIS fourth of reports submitted to PA-PSRS during actual medication administra- involved high-alert medications.10 tion. Most commonly, two patients Wrong-Patient Errors during Among the wrong-patient event reports Administration were prescribed the same medication, submitted, most (26.3%, n = 214) were and one received the medication dose There were 353 wrong-patient errors associated with medical-surgical units, intended for the other (14.3%, n = 41). that occurred during the administration and 22.1% (n = 180) were associated with The second most prevalent contributing node, which includes the range of tasks the pharmacy. The third most common factor was inadequate identification (ID) typically performed by nurses. When care area noted in the reports was the check (12.9%, n = 37), in which the event looking at the processes of administra- emergency department (9.8%, n = 80). descriptions specifically mention failure tion, a majority of events occurred during Page 42 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority Table 1. Medication Storage Areas Involved in Events Occurring during the Medication personnel involved. Of the transcribing Procurement Process, as Reported to the Pennsylvania Patient Safety Authority, July 2011 to events, most errors were due to transfer- December 2011 ring orders into the wrong chart (81.4%, MEDICATION STORAGE NO. OF REPORTS n = 253). Other errors occurred because AREA (N = 55) % OF REPORTS the wrong patient’s label was affixed to Automated dispensing cabinet 42 76.4 the order (18.3%, n = 57), and one error Unknown 6 10.9 (0.3%) involved both a wrong label and Refrigerator 3 5.5 the wrong chart. Pharmacy 3 5.5 Regarding contributing factors, multiple Medication cart 1 1.8 reports mentioned verbal orders (7.4%, n = 23), similar patient names (2.6%, n = 8), and/or the same or similar room to use two patient identifiers and to con- without questioning them. Later, the numbers (1.6%, n = 5). firm identity with patient ID bracelets. In nurse realized that the two patients Nurse took a verbal order for one four reports (1.4%), the nurse used the look very much alike. patient but placed it on the wrong patient’s or family’s acknowledgment of The nurse attempted to administer patient’s chart. The order was faxed the name, which was incorrect, to verify [a medication]. The nurse asked to pharmacy but caught when in identity. Rooming issues also contributed three adults in the room to verify verification stage. to wrong-patient administration errors the patient, since the patient was a (12.2%, n = 35). The nurse either con- Personnel catching and correcting the pediatric patient and no ID bracelet fused the patient with a roommate or error was mentioned in 50.8% (n = 158) was on. All three verified and allowed administered the medication to the wrong of the event reports involving transcrib- the nurse to give the medication to the patient due to similar room numbers. ing. Of these, 81.6% (n = 129) of the patient when it was the wrong patient. Finally, not using the medication adminis- errors were caught by a pharmacist, and tration record (MAR) to properly identify The wrong patient profile was viewed 15.8% (n = 25) were caught by a nurse. the patient also contributed to 7.3% (n = on the screen. The nurse pulled Vico- 21) of events. din® for pain for a patient in 123A Wrong-Patient Errors during but was on the patient in 123B Prescribing Examples of wrong-patient errors during medication profile. The nurse entered administration include the following: The predominant type of prescribing error the room and scanned the medica- involved a prescriber ordering a medication A patient told the nurse that she was tion while still on the 123B profile. on the wrong chart (92.9%, n = 91). Vari- another patient during the morning The scan matched and at this point, ous contributing factors were identified, but medication administration. The nurse the nurse did not notice that he none were associated with more than 4.1% did not check the patient’s [ID] brace- was on the wrong profile. The nurse (n = 4) of reports. In one report, a physician let, and the patient received another approached 123A, scanned [the gave a verbal order for a medication but did patient’s morning medications. patient’s] bracelet, and administered not use the patient’s full name. In another The patient was in the hall, and the the medication without checking the example, a physician mistakenly ordered nurse called the name of a patient. screen to see if the correct patient medications for the patient’s wife, who was The patient came down the hall, and was scanned. located in the same room. the nurse asked the patient if this Wrong-Patient Errors during Examples of wrong-patient errors during was her name. The patient responded Transcribing prescribing include the following: “Yes.” The nurse looked at a picture and then asked the patient where her The second most prevalent node in The nurse found a medication deliv- wristband was since it was not on which errors originated was transcribing. ered to the floor for a patient on an the patient. The patient responded, Transcribing was defined as the process amiodarone infusion. There was no “I took it off a couple days ago.” that involves the transferring of a paper order found in the patient’s chart [for The nurse looked at the patient’s medication order to a patient’s electronic this medication]. The pharmacist picture and asked again, “Are you or paper MAR. Nurses, pharmacists, unit was notified, who reported that the this patient?” The patient responded clerks, and others can perform this task; cardiologist called asking for a “stat” “Yes” and took the medications however, few of the reports identify the amiodarone for a patient but only Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 43 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S gave the patient’s last name. The was still unavailable. There was a In roughly 6% (n = 52) of the events, pharmacist was made aware that Levaquin 750 mg sent for a patient reporters mentioned that one patient the cardiologist was not seeing this in room 465, but he was not ordered was confused with another because both patient. The pharmacist reported that it. When I called the pharmacy to patients were to receive the same medica- no other patient with this name was inquire about it, the pharmacy said tion. While most of the errors occurred in the hospital. It was later discovered they had no recall of them sending during administration, four errors (7.7%) that the patient was in the registra- the Levaquin for 465, but they said originated during prescribing. In one tion area but not yet admitted. The they did recall that it was sent for example, a physician prescribed warfarin doctor had indicated that it was an 456. The pharmacist was made for two patients but switched the doses. urgent situation. aware that we had a bag with two In another example, a nurse confused The doctor came to see the patient, Levaquin 750 in it but mislabeled intravenous (IV) medication bags for two while the nurse was in the room, and with a 465 label on it. of his patients who were on the same discussed the medications he was going A delivery error is made when a medica- medication. In the latter example, the to order. However, since the patient tion that is filled correctly is delivered medications for both patients were stored is in the same room with his wife, the for the incorrect patient, and this most in the same area, and the report did not doctor spoke to both of them. When often resulted in medication placed in the mention the use of mechanisms to con- the doctor told the husband what incorrect patient bin. firm the correct medication (e.g., medications he was going to write, he bar coding). Patient was ordered Fioricet® every also told them to the nurse and went six hours as needed for headache. A I had two patients who were due for to the desk to write orders. While pharmacist who was on the unit was vancomycin IV at 1800 last evening. looking over the copy of the orders, the approached by nursing about the Since I was all the way in the back nurse noticed they were written on an delivery of the Fioricet, as it was not hall, I removed both vancomycin order sheet with the patient’s wife’s in the patient's drawer. The nurse [bags] from the fridge at the nursing ID sticker on it. The nurse went to the happened to look in the medication station. When I hung the medication, wife’s chart and saw that the doctor drawer of another patient and discov- I switched the bags by accident. had written the orders in the wrong ered the Fioricet. About 3.2% (n = 26) of errors involved chart. The nurse called the pharmacy verbal orders, with only one report to stop the orders and called the doctor Contributing Factors Associated describing the use during an urgent to verify that he did not want them situation. ISMP has recommended that on the wife and to take them again as with Wrong-Patient Errors Besides those mentioned above, several verbal orders be limited to use during verbal orders for the patient. emergencies and similar situations.12 The contributing factors that span the medication-use process were identified. following example typifies a verbal order Wrong-Patient Errors during that was transcribed onto the wrong Although the proportions were low, these Dispensing patient’s chart. Fortunately, a nurse had characteristics were present in events that The least number of wrong-patient errors may have been prevented with system investigated and discovered the incorrect occurred during the dispensing node changes (see Table 2). order. However, incorrect verbal orders (5.2%; n = 42), the stage of the medication- are often difficult to catch because they use process that primarily takes place within the pharmacy. These errors were associated with either the processes of fill- Table 2. Contributing Factors and Characteristics of Wrong-Patient Errors, as Reported to ing (57.1%, n = 24) or of delivery (42.9%, the Pennsylvania Patient Safety Authority, July 2011 to December 2011 n = 18). A filling error is made when a CONTRIBUTING FACTOR OR NO. OF REPORTS % OF TOTAL medication prescribed for one patient is CHARACTERISTIC (N = 813) REPORTS dispensed from the pharmacy for a dif- Same medication 52 6.4 ferent patient. Most of the filling errors Verbal order 26 3.2 (70.8%, n = 17) manifested as an incorrect Similar patient name 25 3.1 patient-specific label being applied to a Confusion with discharged patient 11 1.4 medication or medication package. Caught by patient or family 10 1.2 Levaquin® was ordered for a patient Interruption 9 1.1 in room 456, and the medication Page 44 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority necessitate the prescriber or the person documents from discharged patients were errors (see Table 3). While often thought who is receiving the order to realize the mistaken for those of current patients. to occur only during administration, incorrect transcriptions. During the morning assessment, these types of errors were identified in A verbal order was written for Diflu- it was noticed that the previously all phases of the medication-use process. can® 100 mg once daily and A&D infused antibiotic syringe on the IV Unfortunately, most of the reports did ointment as needed on the patient's pole with another patient’s name on not explicitly describe the errors nor chart. Later, another patient was the medication label was connected disclose the causes and contributing fac- complaining of itching, and the nurse to current patient. Correct medica- tors linked to the errors; however, these received a report that an order was tion and dose on the label. The name reports, observations from ISMP, and obtained. Upon investigation, no and date of birth were on the label recommendations in the literature do order was found on the other patient's for a discharged patient, from the suggest strategies that healthcare facili- chart. The charge nurse, while doing previous day, [who had occupied the] ties may consider to decrease the risk of chart checks, found the order on the same room and bed. wrong-patient medication errors. wrong patient's chart. The nurse who The patient in this room was ordered took the verbal order verified that it Improve Patient Verification for a heparin drip based on an ECG indeed was on the wrong patient. All Patient Encounters [electrocardiogram] strip on the While patients with similar names can chart that showed a rhythm of atrial While the Joint Commission has an lead to error-prone situations, only fibrillation. The ECG strip that was NPSG of improving the accuracy of 3.1% (n = 25) of reports mentioned this on the chart did not belong to this patient identification, the proper use of contributing factor. The low prevalence patient but was from the patient who two patient identifiers may still not be per- may be because many hospitals may had been in the room yesterday but formed at all times.13,14 Such verification already have mechanisms in place to had been discharged. The date on should be considered for all patient- prevent confusion between patients with the ECG strip was from yesterday associated tasks, including prescribing, similar names. In fact, the assumption afternoon. The heparin drip was reporting of test results, and communica- that similar names are the cause of most ordered this morning by the cardiology tion of medication information between wrong-patient errors may result in other resident, and the error was found this providers. A proper identification check failure points being ignored. The example afternoon during cardiology rounds not only consists of confirmation with below mentions that two patients had the by the cardiologist. The patient never the patient but also requires confirmation same first letter of their last names, but received any heparin, and the order with the MAR or patient chart, patient this was likely not the only reason for the was discontinued as soon as it was armband, patient-specific medication incorrect transcription. discovered by the cardiologist. labels, and/or other records. An order for Imodium® 2 mg as Finally, some reports described events in Healthcare facilities may consider needed was entered for the wrong which patients or their family members standardizing the two reliable patient patient on the same floor. Both caught wrong-patient errors. Below is an identifiers that should be used for identi- patients involved shared the same example that illustrates one such case. fication and verification. Several reports first letter of their last name. The illustrate examples whereby patients with I was called to the patient’s room by similar room numbers or the same drug order was sent to the pharmacy two the wife who noted, within 10 min- more times after the original was were prescribed, dispensed, or adminis- utes of initiation of infusion, that the tered a dose intended for another patient. entered on the wrong patient. A dif- IV pump read vancomycin but the ferent pharmacist entered the re-sent Overreliance on patient location and the medication bag was labeled as acy- name of the medication ordered may orders on the correct patient. clovir and with a different patient’s have contributed to one event reported to Eleven reports (1.4%) described situations name. Dose immediately discontin- the Authority about a pharmacy techni- in which a patient was confused with a ued and no reaction noted. cian dispensing an insulin pen with the discharged patient. In one example, the label of a previous patient located in the confusion involved a discharged patient RISK REDUCTION STRATEGIES same bed attached to it. In fact, the Joint who had previously occupied the same Commission’s NPSG requires healthcare The reports of wrong-patient events bed. Two other examples described insulin practitioners to use at least two patient submitted to the Authority reveal the com- pens of discharged patients being dis- identifiers (not the patient’s room num- plex nature of wrong-patient medication pensed or used on current patients. Even ber or location) when providing care, Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 45 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 3. Descriptions of How Wrong-Patient Medication Errors Occur, by Node, as treatment, and services. The intent is two- Reported to the Pennsylvania Patient Safety Authority, July 2011 to December 2011 fold: (1) to reliably identify the individual NODE REPORTED EVENT as the person for whom the service or Prescribing Medication prescribed for a wrong patient with a similar room treatment is intended and (2) to match the number service or treatment to that individual.3 Wrong chart selected during prescribing Patient given the wrong prescription Ensure Proper Storage of Patient prescribed the dose for another patient on the same Medications and Patient-Specific medication Documents Patient prescribed medication based on data of another patient Because medications are often dispensed Medication prescribed for a wrong patient with a similar name in patient-specific doses or unit-of-use Medication prescribed for a patient’s relative instead of the patient formulations, store these doses in a Wrong chart selected in the computerized prescriber order entry manner that does not cause confusion system from multiple open charts during retrieval for administration. For Transcribing Order transcribed into the wrong chart patient-specific doses, hospitals often use Wrong label affixed to the order sheet individual storage bins for each patient. If Wrong patient chart selected during transcription due to similar used, clearly label these bins and design name them to facilitate medication delivery and Verbal order transcribed for the wrong patient retrieval. Moreover, some of the reports Orders transcribed for the wrong patient with a similar name describe patients receiving the wrong Dispensing Wrong patient’s label affixed to the medication medication because doses intended for Medication placed in the wrong patient’s bin other patients were placed in the former Medication dispensed for the wrong patient with a similar name patients’ rooms. Dose intended for another patient dispensed when both Similarly, store and return patient-specific prescribed the same medication documents in the patient’s chart. For Administration Patient given a dose intended for another when both prescribed example, a misplaced monitoring sheet the same medication Improper check of patient identification before administration may result in an unnecessary treatment for another patient. Standardizing the Roommate given medication labeling practices for paper documents, Medication administered to a patient in a room with a similar room number monitoring sheets, and lab results can decrease the risk of wrong-patient errors. Improper bar-code scanning procedures before administration Practitioner used the wrong patient’s medication administration Lastly, institute procedures to remove record medications and documents from active Patient administered a dose intended for a patient with a similar patient care areas when patients are dis- name charged. In a few events reported to the Medication in an unlabeled syringe given to the wrong patient Authority, medications prescribed for Medication administered was another patient’s medication that discharged patients remained and were was accidentally left in the room administered to new patients. Patient verified the wrong name before administration Patient administered a medication intended for an already- Use Healthcare Technology Fully discharged patient and Properly Medication administered based on wrong patient’s laboratory data Although not always easy to implement, Medication retrieved from automated dispensing cabinet under technological innovations can enhance the wrong patient’s profile patient safety.15 The paper transcription Wrong medication retrieved from the refrigerator, pharmacy, or errors discussed earlier may have been medication cart avoided with computerized prescriber Note: Error descriptions are based on a review of events reported to the Authority, observations from the Institute for Safe Medication Practices, and errors published in the literature. order entry (CPOE) systems that integrate with pharmacy computer systems. Many of these systems include various safety Page 46 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority features, such as alerts, that can help Hospitals often use ADCs as secure stor- medications. They noticed IV bags with detect inappropriate medication orders. age units for medications without fully labels that had another patient’s name, Although historical studies have shown using system capabilities to prevent errors. and in one event described earlier, a family error reduction up to 81%, CPOE systems An ADC that allows nurses to override member even noticed the medication mis- can also lead to error risk.16 Therefore, a majority of medications essentially match on the IV bag and the IV pump. these systems need to be continually eliminates a pharmacist’s double check of Establish patient education programs to examined and enhanced. In one study, the prescriber’s order. The use of profiled teach patients the importance of accurate extra safety features were added to the ADCs (such that the prescribed and veri- patient identification during all points of existing CPOE system to help physicians fied medications are the only medications contact and how staff should be verifying verify patient identity before signing the that can be removed from the ADC) is their identities. For example, if the facility orders electronically.17 In another study one way to take advantage of built-in uses bar-code identification, encourage done at a pediatric hospital, the patient’s safety checks. the patient to speak up if his armband is photograph was used to prompt the physi- As technology evolves, organizations are not scanned prior to medication adminis- cian to confirm the correct patient prior encouraged to continue to understand the tration. In fact, WHO also “encourage[s] to completing his order.18 Furthermore, patient safety features of new systems and patients and their families or surrogates to many hospitals limit the number of devices, as well as to identify the weak- be active participants in identification, to electronic charts that practitioners can nesses and limitations of technology and express concerns about safety and poten- have open at any one time so that there prevent them from being exploited. tial errors, and to ask questions about is decreased risk that the wrong chart is the correctness of their care.”4 Educate chosen. Finally, Adelman et al. found that Limit the Use of Verbal Orders patients to ask questions about their 10.6% of the wrong-patient prescribing Although essential in emergency medications and the purpose of their errors were juxtaposition errors in which situations, verbal orders in nonurgent medications (e.g., see the Authority's the wrong patient is selected from a list of conditions can result in errors early in Consumer Tips about medication safety). names by mis-clicking.18 the medication-use process that may not To accomplish this, some organizations In addition to CPOE, bar coding can be easily be caught downstream. Standardize have implemented programs in which used to detect and prevent errors dur- policies that detail when verbal orders patients and family members become ing dispensing and administration. For are appropriate, who may receive verbal active partners in ensuring patient safety. example, during the filling process, phar- orders, how to give and receive these These programs include brief safety macists and/or technicians can employ orders, and the safety checks that should orientations for the patient upon admis- bar-code verification of the medication be used to prevent error. In an earlier sion, dedicated hotlines, and educational with the computer-generated patient label. example, the prescriber failed to provide material listing questions that the patient Bar coding during medication adminis- appropriate identification and the phar- should be asking the healthcare practitio- tration can be a reliable double check if macist failed to confirm the patient’s ners who care for them. performed correctly. Some of the reports identity by reading back patient identifiers analyzed in this study stated that bar cod- in the chart. Certain computer systems CONCLUSION ing successfully detected the wrong-patient allow orders to be designated as verbal Wrong-patient medication errors can error; however, a number of reports orders and, thus, require prescribers to occur at any phase of the medication- indicated that improper use of scanning cosign or review these orders. use process. While events reported to prevented the error from being caught. the Authority suggest that these errors In these instances, nurses administered Empower the Patient to Prevent occurred most often during administra- the medication first then scanned the and Detect Medication Errors tion and transcription, implementing patient’s armband second, or nurses failed Engaging the patient and family members safety strategies at all nodes can help to to check for a confirmation from the scan- can be an added safeguard against harm ensure that the correct patient receives the ning prior to administration. ISMP has from an error.20 In several of the reports, correct medication. received many reports similar to the latter patients or family members caught the example and has described this problem Acknowledgments wrong-patient error when they actively in its newsletters.19 Michael J. Gaunt, PharmD, Pennsylvania Patient examined the medications being adminis- Safety Authority, contributed to manuscript tered and questioned the reasons for the preparation. Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 47 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S NOTES 1. National Patient Safety Agency. Stan- http://www.ismp.org/Tools/ 14. Henneman PL, Fisher DL, Henneman dardising wristbands improves patient highAlertMedications.asp. EA, et al. Providers do not verify patient safety [online]. 2007 Jul 3 [cited 2012 8. Gaunt MJ. Medication errors: when identity during computer order entry. Nov 28]. http://www.nrls.npsa.nhs.uk/ pharmacy is closed. Pa Patient Saf Advis Acad Emerg Med 2008 Jul;15(7):641-48. resources/?entryid45=59824. [online] 2012 Mar [cited 2012 Nov 29]. 15. Grissinger M, Cohen H, Vaida AJ. Using 2. Joint Commission. Sentinel event data: http://patientsafetyauthority.org/ technology to prevent medication errors. event type by year: 1995–2Q 2012 [online]. ADVISORIES/AdvisoryLibrary/2012/ Chapter 15. In: Cohen MR, ed. Medication 2012 [cited 2012 Nov 28]. http://www. Mar;9(1)/Pages/11.aspx. errors. 2nd ed. Washington (DC): American jointcommission.org/assets/1/18/ 9. Medication errors in the emergency depart- Pharmacists Association; 2007:411-42. Event_Type_Year_1995_2Q2012.pdf. ment: need for pharmacy involvement? Pa 16. Koppel R, Metlay JP, Cohen A, et al. Role 3. Joint Commission. National patient safety Patient Saf Advis [online] 2011 Mar [cited of computerized physician order entry goals effective January 1, 2012 [online]. 2012 Nov 29]. http://patientsafetyauthority. systems in facilitating medication errors. 2012 [cited 2012 Nov 28]. http://www. org/ADVISORIES/AdvisoryLibrary/2011/ JAMA 2005 Mar 9;293(10):1197-203. jointcommission.org/assets/1/6/ mar8(1)/Pages/01.aspx. 17. Adelman JS, Kalkut GE, Schechter CB, NPSG_Chapter_Jan2012_HAP.pdf. 10. Focus on high-alert medications. PA PSRS et al. Understanding and preventing 4. World Health Organization. Patient iden- Patient Saf Advis [online] 2004 Sep [cited wrong-patient electronic orders: a random- tification [online]. Patient Saf Solut 2007 2012 Nov 29]. http://patientsafetyauthority. ized controlled trial [online]. J Am Med May [cited 2012 Nov 29]. http://www. org/ADVISORIES/AdvisoryLibrary/2004/ Inform Assoc 2012 Jun 29 [cited 2012 who.int/patientsafety/solutions/ Sep1(3)/Pages/06.aspx. Nov 29]. http://jamia.bmj.com/content/ patientsafety/PS-Solution2.pdf. 11. National Coordinating Council for Medi- early/2012/06/28/amiajnl-2012-001055.full. 5. Flynn EA, Barker KN. Research on errors cation Error Reporting and Prevention 18. Hyman D, Laire M, Redmond D, et al. in dispensing and medication adminis- (NCC MERP). NCC MERP index for The use of patient pictures and verifica- tration. Chapter 2. In: Cohen MR, ed. categorizing medication errors [online]. tion screens to reduce computerized Medication errors. 2nd ed. Washington 2001 [cited 2012 Nov 28]. http://www. provider order entry errors. Pediatrics 2012 (DC): American Pharmacists Association; nccmerp.org/medErrorCatIndex.html. Jul;130(1):e211-9. 2007:15-42. 12. Cohen MR. Preventing prescribing errors. 19. Institute for Safe Medication Practices. 6. Institute for Safe Medication Practices. Chapter 9. In: Cohen MR, ed. Medication What does a bar-coding scanner beep Oops, sorry, wrong patient! A patient errors. 2nd ed. Washington (DC): American mean? ISMP Med Saf Alert Acute Care verification process is needed everywhere, Pharmacists Association; 2007:175-204. 2009 Sep 24;14(19):1-2. not just at the bedside. ISMP Med Saf 13. Phipps, E, Turkel M, Mackenzie ER, et al. 20. Aimette SA, Tuohy NR, and Cohen MR. Alert Acute Care 2011 Mar 10;16(5):1-4. He thought the “lady in the door” was the The patient’s role in preventing medica- 7. Institute for Safe Medication Practices. “lady in the window”: a qualitative study tion errors. Chapter 13. In: Cohen MR, ISMP’s list of high-alert medications of patient identification practices. Jt Comm ed. Medication errors, 2nd ed. Washington [online]. 2012 [cited 2012 Nov 29]. J Qual Patient Saf 2012 Mar;38(3):127-34. (DC): American Pharmacists Association; 2007:289-316. LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Identify the nodes involved in wrong- The following questions about this article may be useful for internal education and patient medication errors reported assessment. You may use the following examples or come up with your own questions. to the Pennsylvania Patient Safety 1. Which of the following is the most prevalent node associated with wrong-patient Authority. errors reported to the Authority? — Identify the processes under each a. Prescribing node that were involved in the b. Transcribing wrong-patient medication errors c. Dispensing reported to the Authority. d. Administration — Recognize the causes and con- tributing factors associated with wrong-patient errors. — Select appropriate risk reduction strategies to prevent wrong-patient medication errors. Page 48 Pennsylvania Patient Safety Advisory Vol. 10, No. 2—June 2013 ©2013 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) Questions 2 through 4 refer to the following case. Two patients, Patient A and Patient B, both suspected of having hospital-acquired pneumonia, were located in the same room. The physician taking care of Patient A asked the nurse to order vancomycin for that patient. The nurse had the electronic charts for both Patient A and Patient B open and accidentally entered the medication on Patient B’s chart. The pharmacist verifying the order received a duplicate-medication alert from the computer system and realized that Patient B had already been started on vancomycin two days earlier. She called the nurse to clarify, and the nurse then realized that he had entered the medication on the wrong patient. 2. During which node of the medication-use process did the error occur? a. Prescribing b. Transcribing c. Dispensing d. Administration 3. What risk reduction strategy was in place that helped to identify the wrong-patient error? a. The proper use of bar-code scanning technology by the nurse b. The pharmacist’s use of two patient identifiers during order verification c. The pharmacy computer system’s alert that detected the inappropriate medica- tion order d. The storage of each patient’s vancomycin dose in separate bins 4. Which of the following strategies is most effective in preventing such errors? a. Limiting the use of verbal orders during nonurgent situations b. Implementing a procedure that requires a two-nurse verification to receive a verbal order c. Separating patients who have similar diagnoses into different rooms d. Allowing nurses to only have one patient’s electronic chart open at a time Questions 5 and 6 refer to the following case. A nurse notified the physician that the patient in 216A was ready for her lumbar puncture and intrathecal methotrexate. The physician thought he heard 216B, went to the patient in 216B, and started explaining the procedure to him. The nurse walked in to prepare the patient for the procedure and noticed that the physician was talking to the wrong patient. The right patient received the procedure. 5. Which of the following factors most directly contributed to this event? a. Reliance on the room number to identify the patient b. Lack of standardized safeguards for chemotherapy agents c. Improper use of bar-code scanning of the medication and patient d. Lack of clinical decision support software in the computerized prescriber order entry (CPOE) system 6. Which of the following additional strategies is most beneficial to help prevent such errors? a. Limiting the use of verbal orders during nonurgent situations b. Placing patients receiving high-alert medications in private rooms c. Storing the medication in the automated dispensing cabinet (ADC) until needed d. Using two reliable patient identifiers for all patient-associated tasks Vol. 10, No. 2—June 2013 Pennsylvania Patient Safety Advisory Page 49 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 2—June 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. 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