11.11.2009

Nurses Need a Dose of Lean in Battle Against Medication Errors

Nurses, who play a major role in distributing medication to hospital patients, are trying to take a leading role in stopping medication errors. That is the good news. The bad news is that they are focusing their efforts in the wrong direction.

A recent article from Health Leaders Media describes a study led by Linda Flynn, RN, PhD, associate professor at the University of Maryland School of Nursing. Flynn is also the project director and principal investigator of this Interdisciplinary Nursing Quality Research Initiative (INQRI)-funded study.


"Nurses are the safety net that keeps patients safe from experiencing a medication error," said Flynn. "Our question was, what are the factors that impact this nursing safety net—what are the factors that help nurses in doing their job to intercept medication errors before they reach the patient, and what are the factors that serve as barriers to this safety net?"


The study looked at medication errors, and efforts to stop them, at New Jersey hospitals.


Flynn and her team interviewed 50 staff nurses from 10 hospitals, transcribed the interviews, and analyzed the lines of text for patterns and commonalities. They found that nurses take seven routine steps in the name of medication safety:

  1. Conduct independent review of the medication administration record (MAR) in comparison with the medication order
  2. Perform a focused assessment of the patient prior to administering medication
  3. Question rationale
  4. Prioritize face time with physicians
  5. Encourage patients and families to be the last line of defense for a medication error
  6. Advocate with pharmacy to ensure timeliness of medication delivery.
  7. Clarify orders/handwriting with physicians

Of these processes, Flynn and her team found that numbers 1, 3, 5, and 7 were significantly associated with fewer medication errors.


The problem here is that the focus is on “intercepting” medication errors, to use Flynn’s word. As any lean advocate can tell you, the focus should be on preventing errors from occurring in the first place.

Since I am not familiar with hospital processes for dispensing and distributing medication, I couldn’t say how you do that. But I’m sure a solid lean analysis of those processes could lead to improvements that would have a real impact on the number of errors that occur.

If you know what some of those improvements might be, please share them below.

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