Med errors: Don't overlook the people part of the equation

July 1, 2002

ASHP drug error presentations' highlights



Med errors: Don't overlook the people part of the equation

On a Sunday morning, a pharmacist in the Southeast mistakenly dispensed an adult dose of a narcotic medication for a child. It proved to be a fatal error. Investigation revealed that the pharmacist was on the job that morning just a few days after his wife had passed away.

"Do you think that pharmacist might have had other things on his mind? What was he doing at work on a Sunday morning so soon after burying his wife? What kind of bereavement policy did his employer have?" Anthony F. Grasha, Ph.D., posed these questions in focusing on the "human factors" in medication errors. His basic but often overlooked message: In building a system to minimize and prevent medication errors, don't forget the people part of the equation.

Grasha, professor of psychology at the University of Cincinnati, was the lead-off speaker in the Medication-Use Safety Learning Community at the Summer Meeting of the ASHP in Baltimore. This learning community was a collaborative effort between ASHP and the Institute for Safe Medication Practices (ISMP). It was one of four learning communities at ASHP, which thoroughly restructured its traditional CE schedule to allow in-depth exploration of the designated topic areas over several days.

"In our research, we take a close look at what else was going on at the time mistakes were made," Grasha said. "Often, we find that the pharmacist was fatigued, distracted, or emotionally tense.

"Fatigue," he continued, "is like having a .10 blood alcohol level. Also, it's important to keep in mind that 20% to 30% of stress on the job comes from personal and family concerns. In one case we reviewed, a pharma- cist who erred in filling a prescrip- tion said she'd been worrying because her kids were away on a camping trip and a storm was coming in."

Grasha advised managers to "be careful with people who have 'complicated lives.' They have a tendency to bring those lives to work." In fact, he noted later in an interview with Drug Topics, psychosocial factors may play a role in as many as one-third of medication errors. "This is true in all jobs," he said. "But pharmacists have a tendency to think that because they're professionals, they can leave these problems at the door. It isn't that easy.

"My basic message is that you can't afford to ignore these considerations. If there's a problem affecting an employee's performance, you need to talk it out and make use of options such as employee assistance programs." Grasha has developed a checklist of more than 100 human factors that influence medication safety; for details, you can reach him at

Grasha encouraged his audience to build a NEST in the workplace, based on Nurturance, Empowerment, Structure, and Teamwork.

• Nurturance. "Employees want to feel important," Grasha said, "and they want to know you care. When job satisfaction goes up, error rates go down and productivity improves. When people come under stress and tension, they tend to revert to less efficient habits and take shortcuts."

• Empowerment. Performance may slip when supervisors do not encourage autonomy and show respect. "Employees want recognition, and satisfied employees treat other people better," Grasha emphasized. "If people feel abused within the system, they'll take it out on patients. This is true of physicians, it's true of nurses, and it's true of pharmacists." Low error detection and reporting are also more likely if supervisors have an "in-your-face" management style, fail to establish a climate for excellence and professionalism, and don't give reasons for why something is needed.

• Structure. Within a system that encourages autonomy, professionals also want to know clearly what's expected of them. "People respond to norms that are put in place in an organization and enforced and encouraged," Grasha said. Mistakes occur when explicit rules and procedures either are not available or are improperly applied.

• Teamwork. Mistakes also happen when nurses and other healthcare professionals, working in a culture of not questioning authority, remain silent about a physician's drug order even if they suspect that something is wrong with it. Systems work best when they are rooted in a team spirit, with mechanisms in place to provide regular feedback on performance and double-checking of one another's efforts.

Toward a safer formulary

Two speakers focused on how to avoid errors when reviewing a formulary or adding new drugs to the list. Mary E. Burkhardt, M.S., R.Ph., program manager at the VA National Center for Patient Safety in Ann Arbor, Mich., described a "hazard scoring matrix" that takes into account the severity of a possible event (moderate, minor, major, catastrophic) and the probability that such an event will occur (remote, uncommon, occasional, frequent). The greater the probability and severity of an error, the greater the need for a system of error prevention.

Any team that is set up to evaluate errors, she suggested, should include people who don't know anything about the process—a fresh set of eyes or, as others have described it, the uncluttered perspective of a four-year-old. "It also helps to include people on your staff who tend to be critical of everything," she said. "You can put these people and their critical minds to good use in this situation." The team should also include experts in the subject matter and people who are currently using the process.

Burkhardt emphasized that organizations must tailor solutions to the needs of their own facilities and that a cookie-cutter approach will not work: "Even in the government, we say that if you've seen one VA hospital, you've seen exactly one VA hospital." More information on the VA's Healthcare Failure Modes and Effects Analysis is available at . A variety of training materials are available in video, CD-ROM, Power Point, and other formats.

Bruce M. Gordon, Pharm.D., outlined the role of the medication safety coordinator in identifying areas of greatest risk and in "choreographing the dance" between the medical staff and hospital administration to achieve desired goals. Gordon, director of medical error consulting for BD (Becton, Dickinson and Co.) Healthcare Consulting & Services, suggested asking the following questions before adding a drug to the formulary:

• What medication errors or adverse events have been associated with this drug in other settings? Helpful sources to consult include ISMP's Medication Safety Alerts ( ) and the U.S. Pharmacopeia's MedMarx program ( ).

• Does the medication have to be used in a particular way in order to be effective?

• Is it potentially toxic or subject to numerous drug interactions?

• Is it going to be used in a high-risk area or among high-risk patients?

• Is it a look-alike or soundalike drug? If so, what kinds of educational interventions might be warranted?

• What is the worst-case error scenario with this drug?

• What documents need to be changed to accommodate the new drug—antibiotic order forms, clinical- pathway documents, etc.

There should also be a process in place to identify pending shortages of drugs, Gordon said. One is simply the buyer's index of suspicion, i.e., has he or she had a hard time securing the drug recently? Hand in hand with this should come procedures for using alternative medicines when first-choice drugs are in limited supply. Gordon developed his presentation in collaboration with Bona E. Benjamin, QA pharmacist for the pharmacy department of the Warren G. Magnuson Clinical Center of the National Institutes of Health.

Jeff Forster


Jeff Forster. Med errors: Don't overlook the people part of the equation.

Drug Topics