Nearing zero...reducing grade C medication errors
ABSTRACT:
Medication errors are one of the most prevalent issues that result in patient harm. In July 2009, due to multiple publicized events that occurred in medical institutions across the nation, our Magnet(R)-recognized, urban, academic tertiary hospital created a medication safety operating plan (MSOP). The ultimate goal of the hospital was to reach zero preventable harm from medication errors. This goal was then translated for frontline nurses on a 15-bed general pediatric nursing unit via a team-based goal. Managers established a unit-based team goal for all nurses starting in fiscal year (FY) 2012 to decrease the rate of grade C errors. The use of team goals established at the unit level and aligned with those of the hospital has been linked to improve team performance and increase productivity.1 We focused on grade C medication errors because those classified as grade D or higher didn't occur in the unit at that time. The National Coordinating Council for Medical Error Reporting and Prevention (NCC MERP) developed a standardized classification system to track and delineate medical errors nationally.2 This system classifies medical errors from category A, defined as a circumstance or potential for error yet no real error occurred, to category I, in which the error caused or was related to the patient's death. According to the NCC MERP, category C errors refer to medical errors that reached the patient but didn't cause harm or require additional monitoring or interventions due to the error.2 The hospital's risk management team uses the NCC MERP classification system as a model for grading medical errors. According to The Joint Commission Journal on Quality and Patient Safety, "Medication errors remain among the most common errors in hospitals" and have been extensively documented in various studies and patient-safety investigations.3 In many instances, these medication errors are "caused by faulty systems, processes and conditions that lead people to make mistakes or fail
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