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Good catches strengthen patient safety

Reporting near-miss medication events allows all of us to learn from mistakes — and avoid them in the future.

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Medication errors are the most common adverse events in health care and, as a result, medication safety has become a top priority for health care organizations. The medication management process is complex, encompassing several phases including prescribing, dispensing, administering and monitoring.

The sheer number of drugs administered in health care facilities increases the likelihood of adverse medication events if prevention systems are not in place. Overall, one in 20 patients is likely to experience a medication-related event, and adverse drug events factor into nearly 2 million hospital stays annually.

A bar-coded medication administration, or BCMA, system is an important tool to prevent medication errors. Scanning bar codes helps ensure that the medication being given to the patient matches the specifications of the medication order.

Studies show that proper use of a BCMA system can greatly reduce the risk of errors during medication administration, which, along with medication prescribing, is more error-prone than other stages of the medication use process. BCMA provides the last opportunity to catch a medication error before it reaches the patient.

Asante hospitals and APP clinics continue to focus on BCMA compliance and overall compliance continues to remain strong. Although BCMA can improve medication administration, it still requires user vigilance to prevent errors.

We continue to see medication errors related to not using bar code scanners. One recent adverse event involved a newborn who was receiving routine immunizations at one of our hospitals. The nurse pulled and administered what they believed was the Hep B vaccine. When they went to scan the medication, they immediately realized they administered the wrong medication. They had given Tdap instead of Hep B.

Scanning the medication before administering it likely would have prevented this error, although there were other steps in the process that were missed that highlight the importance of ensuring the five rights of medication administration are followed every time (right patient, right medication, right dose, right route and right time).

Kudos to the nurse who self-reported this incident in Midas Plus, Asante’s patient safety event reporting system. Reporting all patient safety events and concerns, including near misses, helps support a strong culture of safety and ensures we learn from our mistakes.

Asante recently rolled out a “good catch” program focused initially on medication safety that recognizes and rewards staff that report near-miss events. Near misses, or good catches, are patient safety events that have potential to cause harm but did not reach the patient.

Studies suggest that good catches occur up to 100 times more frequently than events that have led to potential or actual harm, but they often go underreported. Reporting good catches allows us to analyze events, identify trends and implement strategies to reduce risk and improve patient safety. Please continue to report all patient safety events, including near misses.

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