Medication Without Harm: Real-life stories
Stories from health care workers
Best practice for nitroglycerin patches
A group of doctors were concerned that heart patients in their hospital’s intensive care unit (ICU) might develop tolerance to the nitroglycerin patches that were prescribed to improve blood flow. The doctors were concerned that ICU staff were not taking the patients’ patches off for an interval of 10 to 12 hours daily, as ICU guidelines required. They devised a test of change to see if this practice could be improved. First, they posted flyers in English in the ICU to promote a daily patch-free interval. These flyers led to improved practices among doctors, but not among the nurses who put the patches on the patients. The doctor group tried again, this time writing the flyer in Arabic, the more commonly spoken local language. They also held training sessions to orient nurses to the correct policy. Within four weeks almost all patients were receiving a 10- to 12-hour patch-free interval every day.
It takes all members of the health care team to bring about improvement. The closer a health care worker is to the practice being changed, the more important his or her involvement is to its success.
*The names and photos used in this story are not real, but the story is based on true events.
Plan-Do-Study-Act
A team of medical professionals at a large hospital noticed a high number of missed medication doses on a ward. They saw a number of possible causes for the missed doses, including the nurse/patient ratio on the ward, lack of floor stocks, pharmacy dispensing issues, and double-checks not done. They undertook a two-part Plan-Do-Study-Act (PDSA) cycle to try to improve the situation.
A PDSA cycle is a rapid test to see how well a proposed change works in real life. The team’s first test consisted of assigning a special nurse to oversee medication use and double-check doses with each staff nurse on the ward. The rate of missed doses decreased from 60% to 12%. The team then tested a second change, asking a senior hospital pharmacist to come to the ward and randomly inspect for problems with medication doses. After this change, the number of missed doses dropped to zero.
Medication safety can easily and economically be improved by looking to see where the problems lie and using simple, proven improvement methodology to implement changes that work.
*The names and photos used in this story are not real, but the story is based on true events.
Patient engagement and health literacy
One institution for providing social care created a patient booklet on safe use of medications. The booklet is a compilation of patient materials based on feedback from patient safety organizations. It includes advice on talking to your doctor, steps for safe use of medicines at home and in the hospital, a chart for calculating creatinine clearance, and an agenda for listing all medicines along with notes on their usage. A companion guide for doctors reminds professionals of steps they should take to prevent errors and harm at all phases of the prescribing process.
The materials grew out of the multi-year journey of one health care worker. This health care professional recognized patient safety education as a need in her country in 2009, and began expanding her horizons to work with the World Health Organization and other groups interested in patient safety. While developing a protocol for high-risk drugs, she saw the need for written materials for patients and professionals. These grew into the present medication guides. She says
“I started out as one lone person talking about a subject that was taboo – patient safety. Today many of us in health care are familiar with the concepts of risk and safety. But I felt an obligation to teach patients about the risks of the system, and especially the most serious and common risks related to medicines. This is a very important issue. Patients should be informed of the importance of medication safety and how to take their medications. When taking several medications care must be taken to prevent interactions that could have the opposite effect from the one that is desired”.
Teamwork between the doctor and patient
An general practitioner has developed a method for dealing with confusion surrounding brand names of medication.
The doctor was concerned that when she prescribed a medicine, the prescription might be filled by any of several different brands, depending upon what the pharmacist happened to have in stock. While the different brands all contained the same medication, the names and packaging varied, meaning that patients could not always recognize their medicines. This was especially a problem for the elderly and for patients taking many medications. The problem was compounded when medication labels were written in English in a language in which many of her patients were not fluent.
The doctor asked her patients to bring her the boxes for their medicines. Together, they looked at the boxes, and the doctor showed the patients the generic name that was always listed beneath the brand name on the label. They then cut out the name and put it in the patient’s wallet. That way, the patients always have a "list" - the collection of little pieces of the box with the generic names - and can check to see what kind of medication they are being given.
Everyone has a part to play in preventing medication errors. When doctors and patients work together, they can come up with creative solutions to help improve medication safety.
*The names and photos used in this story are not real, but the story is based on true events.
Doctors and patients working together
A paediatrician has spearheaded the development of a patient guide to medication safety. The guide is part of a program devoted to developing and celebrating cooperation between mothers and doctors.
The doctor says, “Well-informed mothers are the best agents in preventive medicine”. He adds, “It's amazing how mothers take care of their children, trying to keep them safe in all areas of their lives. Mothers teach the world that while high technology is fundamental, it must be applied with high sensitivity to achieve the desired results”.
The paediatrician urges doctors to work closely with mothers. He says that when mothers are taught to give medicines properly, they will do so accurately, and that mothers are the doctor’s best partners in detecting errors. To achieve these goals he believes that they need tools like the safe medication management guide. However, he says, “I also have no doubt that we must encourage the caregivers and all our patients to imitate what mothers teach us; that is, to permanently develop a culture of safety, and to work as a team, doctors and patients, imitating that incredible person who cares for the future of the world - the mothers.”
*The names and photos used in this story are not real, but the story is based on true events.
Lack of collegiality between doctors and pharmacists
A researcher tells the following story.
Some years ago I interviewed a community pharmacist at a primary health centre. I asked him what he would do if he knew the prescription written by the doctor was incorrect.
Answer: I give what is written on the prescription.<br><br>
I asked: What if the dose was 10 times what it should be? What if the dose was potentially dangerous to the patient
Answer: I give what is written on the prescription.
It turned out that several years before the pharmacist had questioned a prescription that was clearly incorrect, and he had been severely castigated for doing so. Now he just gives what is written on the prescription. No questions asked.
The unequal power dynamic between doctor and pharmacist can be a source of medication errors. Patient safety requires that all members of the health care team feel free to express their concerns.
*The names and photos used in this story are not real, but the story is based on true events.