Reducing Medication Errors Associated with At-risk Behaviors by Healthcare Professionals

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 taken by some healthcare practitioners that could compromise patient safety. Those who engage in at-risk behaviors may do so 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. As healthcare practitioners become comfortable and competent with the tasks at hand, they may have a tendency to engage in at-risk behaviors. 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, s/he 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.

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 at risk behaviors by the front-line practitioners that were linked to the event. 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.  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. 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?"ii. 
  2. 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.  Organizations should start by enhancing staff awareness and reporting of at-risk behaviors and analyzing error reports for common at-risk behaviors. For each at-risk behavior, determine the corresponding safe behavior and the reasons why this behavior was not followed
  3. 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 better approach is to uncover the system-based reasons that lead people’s need to engage in these at-risk behaviors and to decrease staff tolerance for taking risks. 
  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 any perceived drawbacks of the corresponding safe behaviors.  Organizations must identify those undesirable consequences that can be reduced or eliminated. These may include partial or ineffectual use of technology designed to alleviate risks . Facilities can employ a collaborative approach with clinical leadership, Human Resources, and risk management to assure proactive performance review is occurring and there are multiple mechanisms in place for employees to report concerning behaviors. Such a collaborative approach can also identify and communicate triggers that might suggest the need of further investigation of behaviors. 
  5. Motivate through feedback and rewards. Align individual and group motivation to avoid 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 these behaviors occurred. Collect and group these behaviors into categories of circumstances that lead to at-risk behaviors. These circumstances 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.
  6. Involve patients and families in the processes of safe medication administration and monitoring.  Patients do better when they have a say in their own care.  Patients should be able to ask questions about the medication to be administered, method of administration and expected outcome of use including side effects. Staff are less likely to engage in at risk behavior when patients and their families take an active role in managing their care.

At-risk behaviors may include the following:  

I. Patient Information

  1. Not checking patient identification using two identifiers (e.g., name, medical record number, birth date) 
  2. Not checking a patient's allergies before prescribing/dispensing/administering medications 
  3. Not viewing/checking the patient's complete medication profile (or medication administration record [MAR]) prior to prescribing/dispensing/administering medications

II. Drug Information

  1. Prescribing/dispensing/administering medications without complete knowledge of the medication 
  2. Unnecessary use of manual calculations 
  3. Not questioning unusually large doses of medications 
  4. Failure to visually inspect the medication to be administered
  5. Failing to validate/reconcile the medications and doses that the patient states are taken at home

III. Communication

  1. Rushed communication with next shift/covering colleague 
  2. Intimidation/not speaking up when there is a question or concern about a medication 
  3. Use of error-prone abbreviations/apothecary designations/dangerous dose designations [noted less often]
  4. Unnecessary use of verbal orders [noted less often]
  5. Not reading back verbal orders [noted less often]

IV. Labeling, Packaging, Nomenclature

  1. Absent or poor labeling of syringes, solutions, and/or other medication packages 
  2. Grab and go without fully reading the label of a medication before dispensing/administering/restocking medications 
  3. Storing medications with look-alike, sound-alike labels and packaging beside one another

V. Drug Stock, Storage, Distribution

  1. Leaving medications in an unlocked storage area 
  2. Preparing IV admixtures outside of the pharmacy

VI. Environment/Staffing Patterns

  1. Managing multiple priorities while carrying out complex processes (e.g., order entry, transcription, drug administration, IV admixture) 
  2. Holding/admitting overflow patients in inappropriate units/areas 
  3. Failure to adequately supervise/orient staff 
  4. Inadequate staffing based on patient acuity

VII. Patient Education

  1. Prescribing/Administering/Dispensing medications without educating patient 
  2. Disregarding patient's/caregivers concerns about a medication's appearance, reactions, side effects, or other expressed worry
  3. Failure to follow up regarding a medication’s intended effect against the patient’s observed or reported effect.

VIII. Staff Education

  1. Inadequate orientation of new/agency staff 
  2. No organizational incentives to achieve certification or attend continuing education 
  3. Lack of a structured and ongoing staff competency program related to medication use

IX. Quality/Culture

  1. Sacrificing safety for timeliness 
  2. Failure to report and share error information 
  3. Organizational culture of secrecy rather than openness about medication errors 
  4. Organizational culture of finger pointing rather than system change
  5. Failure to address interruptions during medication ordering, preparation, and administration
  6. Failure to properly implement and evaluate new technology

X. Double Checks

  1. Failure to ask a colleague to double check manual calculations before proceeding 
  2. Failure to ask a colleague to double check high alert medications before dispensing/administration 
  3. Failure to ask a colleague to double check high risk processes (e.g., patient controlled analgesia) before proceeding

XI. Teamwork

  1. Reluctance to consult others or ask for help when indicated 
  2. Lack of responsiveness to colleague/patient requests

XII. Technology

  1. Technology work-arounds
  2. Overriding computer alerts without due consideration 
  3. Failure to fully engage available technology   

Additional Resources 

  1. Devine, EB, Hansen RN, Wilson-Norton JL, et al. 2010. The impact of computerized provider order entry on medication errors in a multispecialty group practice. J. Am. Med. Inform. Assoc. 17(1):78–84
  2. Pham, J.C. Reducing Medical Errors and Adverse Events. The Annual Review of Medicine. 2012. 63:447–6
  3. Poon EG, Keohane CA, Yoon CS, et al. 2010. Effect of bar-code technology on the safety of medication administration. N. Engl. J. Med. 362(18):1698–707
  4. Gruman J, Holmes-Rovner M, French ME, Jeffress D, Sofaer S, Shaller D, Prager DC. From patient education to patient engagement: Implications for the field of patient education.  Patient Education and Counseling. March 2010 (Vol. 78, Issue 3, Pages 350-356, DOI 10.1016/j.pec.2010.02.002)

iMarx, D. The Just Culture Community. October Special 2006, Volume 1. (accessed 10/2/06)

iiGeller ES. The Psychology of Safety Handbook. NY, NY: Lewis Publishers; 2001: 33-49.

iiiSmetzer JL. Reducing At-Risk Behaviors. Joint Commission Journal on Quality and Patient Safety. 31 (5). 294-299.

ivKoppel R. 2008 Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety. 2007. Journal of the American Informatics Association. April, 2008. 15:408-423 doe: 10.1197/jamia.M2616

vAssociation of Nurse Executives, Guiding Principles Toolkit