Nursing Intervention in Healthcare Settings Can Reduce Medication Error.

NEW YORK -- Informational Briefing Provided Cross-Discipline Forum for the Discussion of Patient Safety among Frontline Healthcare Workers

Nurses can make a significant mark on improving the nation's patient safety, with particular emphasis on medication errors, according to an expert panel summarizing results today in a national conference call organized by the American Journal of Nursing (AJN), the University of Pennsylvania School of Nursing, and the Infusion Nurses Society.

Today's teleconference was part of a patient safety and error prevention campaign aiming to identify policy and procedural changes and implement best practices in medication administration so the professional community can begin to reduce the alarming rate of errors.

According to the 1999 report of the Institute of Medicine, "To Err is Human," 1.3 million Americans are affected by errors in health care each year, and as a result at least 100 patient deaths occur daily in the US. Add to that the recent assertion that the number may be as high as 195,000 patient deaths each year because of errors, and the level of sensationalism continues to rise. Errors involving medication administration are among the most common.

"Nurses need to be at the table when errors in medication administration are discussed. Nurses are often the last defense in preventing a wrong medication from reaching the patient even though they are frequently unduly held responsible for these errors," said Diana Mason, PhD, RN, FAAN, editor-in-chief of AJN. "We encourage open dialogue among health care professionals, consumers, patients and the media to begin moving discussion into action, and remove the obstacles to safer care once and for all."

This past July, nurses met in Philadelphia to discuss barriers to safer medication administration across various healthcare settings. The results of that closed-door meeting are detailed in a supplemental issue of AJN released this month, and were the impetus for today's briefing.

Issues Raised by the Experts

Jane Barnsteiner, PhD, of the University of Pennsylvania shared some of her work in medication reconciliation. She reported that as many as 80 percent of patients' charts have incomplete information about medication history, indicating the wide margin for error. Dr. Barnsteiner also underscored the need for patients to take an active role in their own care.

Ilene Corina, director of P.U.L.S.E. of New York, a consumer-driven organization aiming to reduce error in healthcare, was involved in the July meeting to lend her perspective to the professional community. "To take back some control, we tell patients it's okay to question those who are caring for you, and many doctors and nurses welcome the participation. We also tell patients to arrange for an advocate who can be the spokesperson for you and your family to provide consistent communication to healthcare providers during an illness," she said when she participated in the July symposium.

A recent study from the University of Montana posited that a breakdown of communication among hospital coworkers appears to affect not only the occurrence of error, but its reporting and prevention. According to the study by Drs. Ann Freeman Cook and Helena Hoas, hospital administrators, physicians and nurses are not in agreement about who is in charge of patient safety; what constitutes a medical error; or how these errors should be reported.

The teleconference was part of a patient safety and error prevention campaign aiming to identify policy and procedural changes and implement best practices in medication administration. It is supported in part by a grant from the Agency for Healthcare Research and Quality (AHRQ 1 R13 HS1436-01)

Note to Editors:

A recording of the teleconference will be made accessible online at www.nursingcenter.com and all of today's participant speakers are available for interview.

Please contact Emily Pihlquist at 212-508-9690 or [e-mail] to arrange interviews with:

Jane Barnsteiner, PhD, RN, FAAN, Director of Nursing for Translational Research, Hospital of the University of Pennsylvania

Rhonda Hughes, PhD, MHS, RN, Agency for Healthcare Research & Quality

Diana Mason, RN, PhD, FAAN, Editor-in-chief, American Journal of Nursing

Ann Freeman Cook, PhD, Director, National Rural Bioethics Project, University of Montana

Mary Alexander, CEO, Infusion Nurses Society

Amber Hogan, MPH, Manager, Public Policy and Safety Advocacy, BD

Rachel Vitoux, RN, MSN, CCRN, Manager, Clinical & Technical Support B. Braun Medical, Inc.

Ilene Corina, Director, P.U.L.S.E. (People Unlimited Limiting Substandards and Errors in health care) of New York

About AJN

The American Journal of Nursing (AJN), the official publication of the American Nurses Association and the largest and oldest circulating nursing journal in the world has been charged by CANS to disseminate key Congress decisions. AJN is published by Lippincott Williams & Wilkins, a unit of Wolters Kluwer Health, a leading provider of information for professionals and students in medicine, nursing, allied health, pharmacy and the pharmaceutical industry. Major brands include traditional publishers of medical and drug reference tools and textbooks, such as Lippincott Williams & Wilkins and Facts & Comparisons, online information services including Ovid Technologies, Medi-Span and SKOLAR, and pharmaceutical information provider Adis International.