CorrectCare

How We Cut Our Medication Error Rate From 85%* to 18%
By Mari C. Knight, RN, MSN, CCHP

A “joke” was going around that our prison had a 99% medication error rate for our population. Real funny.

We knew that figure couldn’t be right, but the rumor did raise concern about our medication delivery system and what our true error rate was. To find out, my manager and I spent a long night examining the medication administration records. By the time we finished at midnight, we had looked at every MAR for the entire month.

What we found shocked us: 85% of the records had some sort of error. Now, this does not mean that in eight out of ten med passes, patients received the wrong drug or the wrong dosage or something equally serious. But we were very critical in our review because we wanted to see the true picture for every moment of the process, from the time a prescription is transcribed to the time a pill reaches an inmate’s mouth. Thus, we marked as an error every failure to comply perfectly with the medication delivery system including the documentation procedures.

Most of what we found did in fact involve recordkeeping errors. Typically there were some blank fields on the MAR form, missing components of the actual prescription on the MAR or failure to initial the transcriptions. Nevertheless we agreed that, no matter how small, these variances were unacceptable. It was time to take action.

Crisis Action Plan
The health care management team immediately developed and set in motion a plan to put a stop to the errors. The first two steps happened simultaneously. We educated staff about the problem and about the proper standards and procedures for medication administration including documentation. They had received this training at orientation, of course, but clearly this needed to be reinforced. We also stressed the need for professional accountability.

At the same time, we instituted daily self-auditing on 100% of the MARs for that day. This meant that every nurse who worked in medication delivery would, at the end of their shift, review their own records and make sure that everything was correct.

Next, I and two colleagues would do a second audit each day. Initially we looked at 80% to 100% of the MARs each day, but we decreased that percentage because we were finding that most of the self-audits were accurate. In addition, we would review audit findings on a weekly and monthly basis to ensure we didn’t miss anything.

Tracking and Training
Armed with our initial review and the periodic audits, we prepared detailed reports so that we could track trends. By identifying the most common and the most egregious types of errors being made, we also knew where to focus our educational messages.

That’s important because the retraining on MAR was not a one-time effort. Rather, we now provide education specifically on medical administration and documentation on an ongoing basis. We review the whole policy and procedure, A to Z, in each session, but we also emphasize areas where we’ve seen slip-ups, such as forgetting to put initials in a certain column.

We’ve increased staff compliance in other ways, as well. We posted a wall chart indicating the audit results for the various compounds. We also reward good performance by, for example, giving movie tickets to staff when their tier has no errors. This transparency and even a bit of peer pressure make for powerful incentives to pay attention to detail.

Great Success
One challenge that lies ahead is our planned transition from paper to electronic medication records. Learning and becoming comfortable with the new technology will take some time, but the principles of good recordkeeping will not change. Our staff members now have a much greater appreciation of the importance of thorough, accurate documentation, and they work hard to achieve 100% compliance.

We’ve had some bumps in the road, but overall we feel that this effort has been a great success. The MAR error rate has dropped to 18%, and while that’s not perfect, we believe that with routine data collection and continuous education, our error rate has stabilized and will even decrease to a more acceptable level.

 — About the author: At the time she wrote this article, Mari C. Knight, RN, MSN, CCHP, was the health services administrator for the New Jersey State Prison in Trenton.

[This article first appeared in the Winter 2007 issue of CorrectCare.]