Working to Prevent Medication Incidents

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Medication incidents are among the most common adverse events in acute care. They can range from a near miss to those that cause harm: wrong dose, drug, time, route or patient, as well as failure to administer at all. Like many of their peers, nurses at the Saskatoon Health Region are determined to minimize the occurrence of medication incidents as much as possible. But pinpointing causes can be a challenge.

That’s where the National System for Incident Reporting (NSIR) comes in. Developed by the Canadian Institute for Health Information (CIHI), this voluntary reporting system allows facilities to report medication and IV fluid incidents. Nurses in Saskatoon have used it to track when incidents are occurring on the front lines and the circumstances around them.

Since joining a pilot of the system in 2008, the region has focused on reports generated from NSIR data. The reports present the top medications involved in errors on a unit, as well as the most prevalent contributing factors. Each quarter, they’re sent to the same nurses who reported incidents to the system.

"Closing the loop and bringing the data full circle makes it relevant for staff," says Norma Noesgaard, the region’s facilitator for Releasing Time to Care.

And because the data is anonymous, no one knows who was involved in the incidents captured in the report.

"It’s a way of providing feedback without pointing fingers or making it personal," she says. "The incidents reported could be yours and probably will be at some point."

Interruptions are well documented as a frequent cause of medication incidents. In Saskatoon, the data had shown that they were regularly among the top two contributing factors, prompting staff to take action.

"The highest number of interruptions were happening during the 8 a.m. medication round," Noesgaard says. "We counted them, took video and tracked it, so we knew that for sure."

To help nurses stay focused on the task at hand, all phone calls on one hospital unit are now directed to a ward clerk during that hour of rounds.

"The feedback has been remarkable. The nurses have loved it," Noesgaard says.

Another unit in the region now uses two-person teams for rounds, with one nurse serving as a buffer to answer questions or call bells, while the other focuses solely on distributing medications.

Overall, the data shows that the number of interruptions has dropped, and nursing units have been able to sustain this reduction over the last year.

Building on that solid change, studying the NSIR data each quarter has become regular practice. Every time the region pulls information from the system, it’s fed back to the nursing units to allow them to track their improvement efforts.

"We have a very good reporting culture. It’s quite positive," says Angela Butuk, the region’s medication safety officer. "NSIR utilization is growing, as people are seeing their data turn into something tangible—something that comes back to them."

Noesgaard says that with its wealth of information, the system has been a very empowering tool.

"People love to see where they’re making good things happen. They want to know the good, the bad and the ugly. This gives us a chance to provide data anonymously, but because it’s posted, it’s really relevant for staff."