Congress Abstracts 2003

61

MEDICATION ERROR PREVENTION IN THE OFFICE SETTING. Kathleen Shuey, MS, RN, AOCN^®, CS, Dori Greene, MS, RN, AOCN^®, and Dianne Richardson, RN, OCN^®, U.S. Oncology, Houston, TX.

The USON network, which consists of over 450 sites of service located in 28 states, is concerned with promoting medication safety and preventing medication errors. The Quality of Care (QOC) Committee has proposed the development of a comprehensive medication error prevention program to be implemented at the practice level. The program purpose is to reduce number of medication errors throughout the network, establish a safe mechanism for processing orders, implement systems/process changes that reduce the risk of future errors and improve patient care, and provide guidelines for safe medication administration.

In 1999, the Institute of Medicine released the report “To Err is Human.” Available data suggested that anywhere from 44,000–100,000 inpatient deaths/year are due to medication errors. The estimated cost runs anywhere from $17–$29. This cost includes additional medical care, lost income and household productivity, and disability. Despite having practice level performance improvement committees, few resources focus on prevention. A review of medication variance records revealed that our data was incomplete and did not allow for effective problem solving and trending. The first step in the prevention program development was to revise the current variance-reporting tool to obtain complete data concerning medication related “events.” This included information on “near misses.” Other recommended program components include a staff education program, promoting a non-punitive culture, best practice tools, a clinical tips sheet, and a similar drug name list. Two additional components will involve database development and determination of an accurate denominator for the number of admixtures prepared.

Some tools and resources have been shared with network clinical leadership, but further dissemination to all clinical staff is needed.

Future plans include moving the educational program into an intranet, web-based offering to provide sharing with all clinical staff. Additionally, the best practice tools will provide individual sites a development plan for the implementation of procedures and practices to minimize the risk of errors. Ongoing monitoring and reporting will occur at a network level through the USON Safety Officer. Continuing evaluation will allow for development of additional tools, resources, or guidelines, as needed, resulting in a safe environment for patients to receive cancer treatment.