Medication error culture of fear

[ethyl]

Does anyone else work in job where you're afraid to report an error?

Medication errors are getting heavily monitored by metrics at my institution and are now a small part of departments' staff bonuses. Seems like a great way to discourage error reporting if it might affect your pay increase. Write ups for med errors have also been on the rise for nursing and pharmacy. Most common errors reported are heparin drip rate changes done wrong by nursing, delay of treatment due to pharmacy or a core measure antibiotic being mistimed by pharmacy. After talking to nurses, there is definitely a fear of reporting med errors because it's a guaranteed write up for the other person and 3 write ups and you're fired. The same goes for the pharmacists, where the only thing reported to management is a severe error that we know reached the patient and will end up getting heard about anyways.

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[PharmEcon]

Med errors are certainly underreported in any practice setting for obvious reasons. Many institutions are moving towards less-penalty or even no-penalty reporting systems as feasible to encourage reporting though. Seems silly to set bonuses based on error rate though- that is just asking to make the issue worse.

 

[opinionfree]

I've always noticed error reports are usually undertaken when: either a patient is actually affected by the error (good reason), or if your at odds with a colleague (bad reason). The latter, being of much more concern. Seems every pharmacist, I've encountered since returning to work, spends entirely too much time and effort reporting EVERYTHING the other pharmacist does or doesn't do. The atmosphere in the pharmacy is toxic.

e.g. You put safety cap on. Patient no want safety cap. I write you up. HAHA.
MD say 3 refill, you only give 2 refill. I write you up. HAHA.
You have coffee in pharmacy. I write you up. HAHA.
Patient say, you not nice enough. I write you up. HAHA.
And yes, every time someone shares that they are reporting someone, for something, they end it with the very passive aggressive and quite threatening, HAHA.

These may not all be 'true' errors, but they set a very high mark of anxiety and fear for job security. Which in turn, sets a higher chance for making 'real' medication errors. Supervisors and managers are already looking for reasons to lower your raises, bonuses and to fire you. Don't help them.
Of course, if a patient is affected by the event, REPORT IT. If the patient is 'near' affected, make everyone aware, utilizing a strongly worded hypothetical scenario. If you dislike the other pharmacist or need a corporate 'gold star' for self-validation, go get therapy.
Most errors can be avoided by simply slowing down. If you're unsure of something, look it up. If you have questions, wait for the answers. Never guess. Lessen the stress of your position, by playing well with the other pharmacists you work with, and you'll catch issues before they become errors.

 

[Gombrich12]

opinionfree, that sounds like a toxic work enviroment. Is there anyway for you to transfer to another store? In all my years the only errors that were reported were the ones that went out to the patient. I've never broke that rule and always report even if I made the error.

 

[thephoenician88]

I've always noticed error reports are usually undertaken when: either a patient is actually affected by the error (good reason), or if your at odds with a colleague (bad reason). The latter, being of much more concern. Seems every pharmacist, I've encountered since returning to work, spends entirely too much time and effort reporting EVERYTHING the other pharmacist does or doesn't do. The atmosphere in the pharmacy is toxic.

e.g. You put safety cap on. Patient no want safety cap. I write you up. HAHA.
MD say 3 refill, you only give 2 refill. I write you up. HAHA.
You have coffee in pharmacy. I write you up. HAHA.
Patient say, you not nice enough. I write you up. HAHA.
And yes, every time someone shares that they are reporting someone, for something, they end it with the very passive aggressive and quite threatening, HAHA.

These may not all be 'true' errors, but they set a very high mark of anxiety and fear for job security. Which in turn, sets a higher chance for making 'real' medication errors. Supervisors and managers are already looking for reasons to lower your raises, bonuses and to fire you. Don't help them.
Of course, if a patient is affected by the event, REPORT IT. If the patient is 'near' affected, make everyone aware, utilizing a strongly worded hypothetical scenario. If you dislike the other pharmacist or need a corporate 'gold star' for self-validation, go get therapy.
Most errors can be avoided by simply slowing down. If you're unsure of something, look it up. If you have questions, wait for the answers. Never guess. Lessen the stress of your position, by playing well with the other pharmacists you work with, and you'll catch issues before they become errors.

Wow, do we work in the same pharmacy? I had to deal with the exact same BS>

Oh you put 1 pack instead of 2? I WRITE YOU UP

I agree about slowing down, but you can't be too slow...

 

[Sparda29]

When I spot an error that someone else made, I quietly fix the error and just leave a note for them about it in their inbox or quietly show them without being a jerk about it.

 

[rph3664]

I once got in trouble because I found out about a vancomycin dose that hung on a pole by the patient's bed for 16 hours without actually being infused, and wrote it up.

(headdesk)

I wonder the responsible nurse had naked pictures of, KWIM? My response was, "Why do we do this in the first place if we can't report big mistakes like this one?"

There were several pharmacists who didn't realize that a copy of their reports were seen by nursing, and would write things on them like "This nurse needs to pull her head out of her butt." Even if they were right, that's just unprofessional, and they did get in trouble for it..

 

[xiphoid2010]

Some people are motivated by recognition and success, but as many if not more require a threat to their wallet to do their duties. So every organization uses both carrots and sticks as means of motivation. An appropriate amount of fear is needed, certainly for the saftey of the patients.

Ps, use something like the NCC MERP system to track med errors.

 

[StellargalS]

The problem is how it all plays out. Kowtow to the bloated rotting pig head on a stick and maybe you work another shift. Humans are at the top of the food chain and that is all.

 

[mustang sally]

We have a no-penalty reporting system here. Having said that, I am still not a huge fan of doing write ups on myself or others if for no other reason than I know that my boss (or the other person's boss) is going to see it and know that we screwed up. I do usually fill them out if the med error reaches the patient though.

 

[xiphoid2010]

One of the things I learned in management is that you can't be friends with everyone. In any department of a significant size, someone will always think they are special or unhappy for one reason or another. You just have to set the rules, be objective and do your duty.

 

[Sparda29]

One of the things I learned in management is that you can't be friends with everyone. In any department of a significant size, someone will always think they are special or unhappy for one reason or another. You just have to set the rules, be objective and do your duty.

I'm generally on good terms with my director but what I can't stand about him is when he acts like he's doing you a favor when in reality, what he did was part of his job. "Sparda, I got these 2 guys to cover these days so you can have your 1 week vacation, and I spent 4 hours at home doing this." Okay... do you want a cookie? I'm taking the vacation regardless. Airfare tickets I bought 4 months ago, it's your fault that you only post schedules 1-2 weeks ahead of time.

Or... hey guys look at all the Pyxis machines I got!!! Or... hey guys look we're outsourcing TPNs now (actually that was a nice favor).

 

[spacecowgirl]

We have a pretty robust error reporting program and reporting is heavily encouraged. As a result, I think there is too much reporting about stupid stuff and little learning comes out of most of these reports so I'm not sure how much it actually helps. We aren't penalized for errors though.

 

[Old Timer]

Where I am you are more likely to get fired for NOT reporting an error than for reporting one. That being said, I don't report things like wrong doctor or missing refills or other non-clinical issues.

 

[xiphoid2010]

I'm generally on good terms with my director but what I can't stand about him is when he acts like he's doing you a favor when in reality, what he did was part of his job. "Sparda, I got these 2 guys to cover these days so you can have your 1 week vacation, and I spent 4 hours at home doing this." Okay... do you want a cookie? I'm taking the vacation regardless. Airfare tickets I bought 4 months ago, it's your fault that you only post schedules 1-2 weeks ahead of time.

Or... hey guys look at all the Pyxis machines I got!!! Or... hey guys look we're outsourcing TPNs now (actually that was a nice favor).

Maybe it's just your perception that he's doing that when he's just giving out info.

People often like to think management is sitting on their asses. Unlike dispensing meds which is plainly visible, DOPs crunching financial numbers, tracking errors, meetings, doing performance evals, getting paperwork in place for the board and joint comission... etc is often invisible to the staff. So some managers will broadcast the stuff they do. Come to think of it I have done it from time to time, even though people don't have to know or even care. And also goes upward, just so that people above don't start thinking the lack of problems in the pharmacy department is a result of not communicating rather than I got thing handled.

Griping and judging about management is a favorite past time in most organizations. Part of that is stemming from ignorance, part also comes from the what I said before "you can't keep everyone happy every time". I like my CEO overall, but me and other directors still likes to gripe and make fun over lunch or happy hours just because we can. At the end of the days though, I'm not a complainer like some others, I just go do my duties.

 

[xiphoid2010]

double post

 

[Sparda29]

Maybe it's just your perception that he's doing that when he's just giving out info.

People often like to think management is sitting on their asses. Unlike dispensing meds which is plainly visible, DOPs crunching financial numbers, tracking errors, meetings, doing performance evals, getting paperwork in place for the board and joint comission... etc is often invisible to the staff. So some managers will broadcast the stuff they do. Come to think of it I have done it from time to time, even though people don't have to know or even care. And also goes upward, just so that people above don't start thinking the lack of problems in the pharmacy department is a result of not communicating rather than I got thing handled.

Griping and judging about management is a favorite past time in most organizations. Part of that is stemming from ignorance, part also comes from the what I said before "you can't keep everyone happy every time". I like my CEO overall, but me and other directors still likes to gripe and make fun over lunch or happy hours just because we can. At the end of the days though, I'm not a complainer like some others, I just go do my duties.

I know he does a lot of work. It's just frustrating sometimes because the things I want him to do are not being done. Like adding tramadol into the ER pyxis. We have Percocet, Oxycontin, Morphine, Hydromorphone, Diazepam, Alprazolam, Lorazepam, and more narcotics that I can't think of right now in the Pyxis. How long does it take to create add a slot in for Tramadol? Instead, every time the doc orders Tramadol I gotta verify it, nurse comes over and wants it, I have to go take it out of the safe and inventory the tramadol, etc.

I've been asking him for the last 6 months to get the P&T to add a pharmacist protocol for ordering labwork. (We can't even ****ing order labs even if the doc calls us and asks us to order the labs since he's away from the hospital and can't enter orders.)

 

[lwales]

Does anyone have any thoughts on the idea that deaths caused by medical errors are the 3rd leading cause of death in the US?? Why are these errors not considered as cause of death??

 

[sunakuma]

How's everyone's thought on "culture of safety" or "just culture"? My school talked about this mentioning that by encouraging reporting errors we can do root cause analysis and develop protocol or systems in place to prevent those similar errors from happening. Is it practical? Dose most hospital do that? (or retail?). If say a pharmacist made an error due to understaff and worked long hours, and the error reached patient. Who is liable? Company's fault by understaffing pharmacist, or pharmacist own fault? I would no't think company will increase more tech hour or have more overlapping pharmacist so everyone can work carefully to prevent error.

 

[Niosh]

How long does it take to create add a slot in for Tramadol?

We have Omnicell, but I imagine it's very similar. It's super easy, takes like 15 minutes max. Unless there are no free slots in the machine, then it could be a pain. But really its a simple matter to run a report on what is used least and swap it with tramadol.

Does anyone have any thoughts on the idea that deaths caused by medical errors are the 3rd leading cause of death in the US?? Why are these errors not considered as cause of death??

I don't really believe that metric. Maybe it is true, but I feel like they might be defining "medical error" in a way that most healthcare professionals would not. I haven't had time to dig into the issue though.

 

[lwales]

We have Omnicell, but I imagine it's very similar. It's super easy, takes like 15 minutes max. Unless there are no free slots in the machine, then it could be a pain. But really its a simple matter to run a report on what is used least and swap it with tramadol.


I don't really believe that metric. Maybe it is true, but I feel like they might be defining "medical error" in a way that most healthcare professionals would not. I haven't had time to dig into the issue though.

According to the Institute of Medicine, medical errors by themselves possibly account for 44,000 to 98,000 deaths annually. I have also seen reports that argued that these errors may be contributed to the large increase of outpatient visits along with the large decrease in number of inpatient days. Due to recent financial pressure, multiple institutions have worked to decrease the average duration of stay for patients. Could this be the cause of the growing deaths by medical errors?

 

[gwarm01]

I worked at a just culture facility. You didn't get in trouble if you caused an error, but you would sit with the med safety officer and try to determine the cause. It could be frustrating because you always had the sense that this person, despite being a pharmacist, didn't have a good grasp of current practice since they had been in administration for so long. It felt like you were on trial and had to present your case. It wasn't really like that, but for some of us it was a point of personal pride to prove you were in the right. Especially since med errors were most often reported by nurses who were even more clueless than the safety officer, but have already influenced their view since they wrote a report.

Anyway, at least there were no punative actions. The final report, which you sign, is placed in your file. I've always assumed that was on standby to justify any firing if you became a problem.

 

[ldiot]

Reporting every wrong doctor or wrong refill number is just suicide. Sure... if the patient saw the wrong doctor on the vial and delayed treatment because of it then you might write it up because it had a negative effect but this stuff is just common sense.

At the same time if you dispense wrong dose/drug/directions and don't report it you will land yourself in some major trouble if they find out. It's just a balance... use common sense. Never ever hide a significant error but at the same time don't report every little thing in fear.

 

[lwales]

Has anybody here been a victim of a medical error or known someone that has been a victim?

 

[owlegrad]

Has anybody here been a victim of a medical error or known someone that has been a victim?

Are you offering to represent me if so? Or is there a number I should call?

 

[Promethean]

Does anyone have any thoughts on the idea that deaths caused by medical errors are the 3rd leading cause of death in the US?? Why are these errors not considered as cause of death??

Are they, though?

Are they really?

Look a little deeper into what is being considered an error in those reports.

Patient developed a bedsore? Medical error. They should have been being turned and repositioned more frequently. Oh, they were actually in such extremis that even with frequent repositioning, they were going to develop that same wound? Still, we have defined bed sores as errors. Doesn't matter if it isn't iatrogenic. It counts against us in the metrics.

Patient fell getting out of bed. Medical error. Patient was not allowed to be restrained. Patient had call bell in reach, had been advised to call for help, had been frequently re-educated on the importance of not getting up alone, decided to do it anyway, fell and broke a hip? Medical error.

Patient given a drug that reacted poorly with the others they were taking. Medical error. Patient withheld their full drug list from the nurses and physicians who asked for the information, choosing not to disclose their use of various herbal and other alternative therapies, and not mentioning their illicit drug use when asked. Still. Medical error.

Patient aspirates when they eat. Have an NPO order. Family brings them food because the hospital is starving them... aspirate and die of pneumonia? Medical error.

When you define everything as a medical error, no matter how little control the health care team had over the matter, then yes, it is easy to get to the third leading cause of death.

 

[Promethean]

I'm not saying that errors never happen. I am saying that the numbers are being wildly inflated by people who have agendas.

 

[BenJammin]

Board of pharmacy statistics on med errors aren't to be taken seriously since most errors don't result in patient harm and thus they don't get reported to the board.

 

[Michael_Scott]

Wow, do we work in the same pharmacy? I had to deal with the exact same BS>

Oh you put 1 pack instead of 2? I WRITE YOU UP

I agree about slowing down, but you can't be too slow...

that is exactly what I thought..seems like more hospitals are adopting this culture.

 

[Dalteparin]

Are you offering to represent me if so? Or is there a number I should call?

 

[BidingMyTime]

How about giving kudos to the poster who brought this for-all-intents-and-purposes-dead-thread back to life?

Some people are motivated by recognition and success, but as many if not more require a threat to their wallet to do their duties. So every organization uses both carrots and sticks as means of motivation. An appropriate amount of fear is needed, certainly for the saftey of the patients. Ps, use something like the NCC MERP system to track med errors.

It is a tricky balance to get this right. One side of the pendulum assigns no fault ever, so people have little incentive to care. On the other side of the pendulum, people are punished so severely for errors, that everyone wants to hide them, which of course hurts patients, as well as increasing the likelihood that similar errors would be made in the future.

I think in the 2000's, the pendulum had swung too far to assigning no error, I think at this point it is starting to swing up too close to the punishment side. But getting the balance right is very difficult, especially since individuals and workplace cultures vary so much.