Harm from high-risk medicines can be reduced by putting interventions in place to address the reasons for an error occurring. Interventions can include guidelines, staff education and system improvements, which reduce the risk of errors being made and prevent potential harm to the patient.
Removing the potential for error is the most effective error prevention strategy. This type of system change is called a high leverage strategy, for example, not stocking, or locking away, potassium chloride concentrated injections to prevent incorrect administration. Other high leverage strategies are automation and computerisation.
Medium leverage strategies include standardisation, independent double checking and using checklists. These strategies do not eliminate hazards but reduce the likelihood of errors occurring.
For example, independent double checking of the dose calculation can prevent overdose due to calculation error. The ‘independent’ factor is the important part – performing the calculation independently and comparing it your colleague’s calculation reduces the chance of error.
Low leverage strategies include guidelines, protocols, education and training. For example, a protocol for the management of anticoagulants including unfractionated heparin and warfarin will help prescribers and administrators manage these medicines. Both medium and low leverage strategies require constant updating and reinforcement to maintain knowledge and currency. The next edition of Medication Safety Watch discusses leverage strategies in more detail. Subscribe to Medication Safety Watch.
It is important to also recognise human factors when preventing harm and errors. Human factors encompass a range of things that can influence people and their behaviour such as environmental, organisational, job factors and individual characteristics. Some common human factors that can increase risk are:
Multiple patient handovers, hierarchy and cultures that discourage challenge can all contribute to errors being made. Using briefings and debriefings can help teams develop a shared understanding of a patient or planned procedure. Communication tools like SBAR (situation, background, assessment, recommendation) can help make conversations succinct, and clarify information and expectations of actions required.
Error-prevention strategies should be varied and focus on human factors and system issues. They can include all three leverage strategies, but always choose the strategies that will have a higher impact on preventing medication errors whenever possible.
Join the preventing error and harm webinar on 27 February 2015 to explore system changes and human factors further.