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Eliminating Workarounds Prevents Medication Errors

Matt Phillion, for HealthLeaders Media, July 1, 2009

In an effort to eliminate medication errors, Central Vermont Medical Center (CVMC) has reexamined its process of charting medication errors, identifying workarounds, and other potential areas where the process can be derailed.

"We have a documentation system which includes an adverse event report," says Barb Sharp, RN, MS, CPHQ, CPHRM, quality manager with CVMC. "The electronic form is completed by the medical area that discovered the error."

This report is structured to show how and when the physician was notified of the error. It also tracks the stage in the process where the error first occurred.

A description of the event is submitted electronically, which goes to the chairman of the medication use committee. It also routes to the pharmacy director and quality manager.

"I, as quality manager, look at all of these and conduct follow-up," says Sharp.

Missed doses

CVMC uses primarily an electronic medical record, but still has certain units using manual administration record.

"We don't see a missed dose very often on the units using the EMR," says Sharp. "The majority of errors occur with the MAR—patients get so many medications these days it's easy to miss. With the EMR, it won't let you move on until you've satisfied" the dose requirements.

Missed doses also come into play when dealing with vaccinations for the flu or pneumonia. In certain cases, a nurse workaround is nearly required.

"If the patient has refused the vaccine or they aren't eligible for it, there would have to be a nurse override or nurse hold to make that happen," says Sharp.

The process is in some ways more challenging than it really should be, Sharp explains. The facility has a flu vaccine team, and the vaccinations are on the standing orders.

"For whatever reason, if the patient didn't need the medication, it comes up on the EMR as part of the standing orders," says Sharp.

The team has brought the hospital's Information Systems department on board to fix this to avoid workarounds and allow users to identify when the patient has refused the vaccine or other reasons why the dose is not given.

"You've got to be sure (the process) makes sense," says Sharp. "One of the easiest things for a clinician to do, if a process is cumbersome, is find a workaround."

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