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Reducing Medication Errors Associated with At-risk Behaviors by Healthcare Professionals Adopted June 8, 2007 It is human nature to look for quicker and easier ways to accomplish tasks, but these actions may lead to or be a result of at-risk behaviors. At-risk behaviors are actions in which healthcare practitioners sometimes engage that may compromise patient safety. Practitioners often use at-risk behaviors because the rewards are immediate and the risk of patient harm seems remote, making it difficult to motivate people to always choose the safest way to work. Practitioners have a tendency to engage in at-risk behaviors as we lose the perception of risk when we become comfortable and competent with the task at hand. These behaviors often result in convenience, comfort, and saved time. The perceived benefits of taking shortcuts rapidly leads to continued at-risk behaviors, despite practitioner's possible knowledge, on some level, that patient safety could be at risk. In addition, as one practitioner has apparent success with an at-risk behavior, they will likely influence fellow practitioners until that behavior becomes a standard practice. These behaviors often emerge because of system-based problems and complexities in healthcare organizations. Using the at-risk behavior in Table 1, a review of 523 random narrative reports, with a NCC MERP harm index of Category C or higher, from the USP-ISMP Medication Errors Reporting program (MERP) and USP's MEDMARX® revealed the most common at-risk behaviors: Engaging in "Grab and go" without fully reading the label of a medication before it is dispensed, administered or restocked; Intimidation or reluctance to ask for help or clarification; Failure to educate patients; Using medications without complete knowledge of the medication; Failure to double check high-alert medications before dispensing or administering; Not communicating important information (e.g., patient allergies, diagnosis/co-morbid conditions, weight, etc.). Establishing an Organizational Culture to Help Minimize At-risk Behaviors: When patient harm occurs, an organization often focuses on the "sharp end" of the medication-use process, such as front-line practitioners that were involved to the event who engaged in the at-risk behaviors. However, punishment based only on the outcome when other instances of at-risk behavior by an individual or group go unnoticed can send the wrong signal to staff. (1) These behaviors often emerge because of system-based problems within healthcare organizations, for example, an organizational culture with a high tolerance of at-risk behaviors. (2) Unnecessary complexity in processes also provides many opportunities for practitioners to take risks when providing care to a patient. The National Coordinating Council on Medication Error Reporting and Prevention makes the following recommendations to reduce medication errors associated with at-risk behaviors: 1) Eliminate organizational tolerance of risk. Organizations, somewhere along the way, may have tacitly approved or overlooked certain at-risk behaviors. Most organizations have allowed these at-risk behaviors to grow because they have resulted in savings of time and/or resources. To determine if the organization's culture is tolerant to at-risk behavior, organizational leaders should ask themselves, "Does my organization tend to "punish" safe behavior, and/or allow at-risk behavior?"(2). 2) Determine system-based reasons for risk taking behavior. Although it is commonly believed that one of the easiest ways to control behavior is to create a policy and discipline individuals who breach it, this strategy does not uncover the system-based reason that may lead to these breaches. The solution is to learn why people need to engage in these at-risk behaviors, by uncovering the system-based reasons, and to decrease staff tolerance for taking risks. The goal is to eliminate the system-wide incentives for the at-risk behavior and to increase the incentives for desirable behavior. 3) Increase awareness of at-risk behaviors. To improve safety, it is more important to reduce staff tolerance of at-risk behaviors than to increase their compliance with specific safety rules. (3) Organizations should start by enhancing staff awareness and reporting of at-risk behaviors. Analyze error reports in your organization for common at-risk behaviors. For each at-risk behavior, determine the corresponding safe behavior and the reasons why this behavior was not followed. Examples of at-risk behaviors can be found in Table 1. 4) Eliminate system-wide incentives for at-risk behaviors. The most important step after identifying at-risk behaviors is to uncover and reverse consequences that lead staff to believe the positive rewards for at-risk behaviors outweigh the perceived negative rewards for the corresponding safe behaviors. (4) Organizations must identify those undesirable consequences that can be reduced or eliminated. 5) Motivate through feedback and rewards. Align individual and group motivation to avoid undesired at-risk behaviors. Often, staff may believe that the organization's priority is efficiency and productivity. Ask staff to document one at-risk behavior and one safe behavior each day, along with the conditions under which they occurred. Collect and group these behaviors into categories that can be identified as circumstances that lead to at-risk behaviors. These should be reviewed and acted upon by multidisciplinary committees at each organization. The safe way to do something must be reinforced with staff as a component of an uncompromised value system. Support, encouragement, and recognition/reward programs for all who meet behavioral criteria must be ongoing. References Marx, D. The Just Culture Community. October Special 2006, Volume 1. http://www.justculture.org/downloads/newsletter_oct06special.pdf (accessed 10/2/06) Institute for Safe Medication Practices. (2004). Reducing "at-risk behaviors". ISMP Medication Safety Alert!, 20, 1-2. Geller ES. The Psychology of Safety Handbook. NY, NY: Lewis Publishers; 2001: 33-49. Smetzer JL. Reducing At-Risk Behaviors. Joint Commission Journal on Quality and Patient Safety. 31 (5). 294-299. Table 1. At-risk behaviors used to drive review I. Patient Information Not checking patient identification using two identifiers (e.g., name, medical record number, birth date) Not checking a patient's allergies before prescribing/dispensing/administering medications Not viewing/checking the patient's complete medication profile (or medication administration record [MAR]) prior to prescribing/dispensing/administering medications II. Drug Information Prescribing/dispensing/administering medications without complete knowledge of the medication Unnecessary use of manual calculations Not questioning unusually large doses of medications Failing to validate/reconcile the medications and doses that the patient states are taken at home III. Communication Rushed communication with next shift/covering colleague Intimidation/not speaking up when there is a question or concern about a medication Use of error-prone abbreviations/apothecary designations/dangerous dose designations Unnecessary use of verbal orders Not reading back verbal orders IV. Labeling, Packaging, Nomenclature Not labeling or poor labeling of syringes/solutions/other medication packages Grab and go without fully reading the label of a medication before dispensing/administering/restocking medications Storing medications with look-alike labels and packaging beside one another V. Drug Stock, Storage, Distribution Leaving medications in an unlocked storage area Preparing IV admixtures outside of the pharmacy VI. Environment/Staffing Patterns Managing multiple priorities while carrying out complex processes (e.g., order entry, transcription, drug administration, IV admixture) Holding/admitting overflow patients in inappropriate units/areas Failure to adequately supervise/orient staff Inadequate staffing based on patient acuity VII. Patient Education Prescribing/Administering/Dispensing medications without educating patient Disregarding patient's/caregivers concerns about a medication's appearance, reactions, side effects, or other expressed worry VIII. Staff Education Inadequate orientation of new/agency staff No organizational incentives to achieve certification or attend continuing education Lack of a structured and ongoing staff competency program related to medication use IX. Quality/Culture Sacrificing safety for timeliness Failure to report and share error information Organizational culture of secrecy rather than openness about medication errors Organizational culture of finger pointing rather than system change X. Double Checks Failure to ask a colleague to double check manual calculations before proceeding Failure to ask a colleague to double check high alert medications before dispensing/administration Failure to ask a colleague to double check high risk processes (e.g., patient controlled analgesia) before proceeding XI. Teamwork Reluctance to consult others or ask for help when indicated Lack of responsiveness to colleague/patient requests XII. Technology Technology work-arounds Overriding computer alerts without due consideration Failure to fully engage available technology © 1998–2008 National Coordinating Council for Medication Error Reporting and Prevention. 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