High-alert Medications: Shared Accountability for Risk Identification and Error Prevention

Abstract

In an ideal world, medical error would never occur and all patients would be discharged from the emergency department remarkably better than when they arrived. Although this may certainly sound like a fairytale, the risks associated with providing care in most ED settings are very common and very real. Don't be fooled. Risk is everywhere, and it can come from many sources, both internal and external to the department, making risk difficult in some situations to anticipate or control. Risk can sometimes be subtle or not easily recognizable, and it is often disguised as a common alteration in procedure or process that is easily bypassed and unnoticed for what it really is . . . an error waiting to happen. Because the majority of emergency departments around the country successfully navigate risk every day, it is often accepted as “that's the way it is around here.” It is human nature to get used to the risk. It is also especially easy for the experienced staff member to become complacent to the risk and to not see it or recognize it as “risk” until something goes terribly wrong. 1 Grasha AF Watch out for this turkey—Complacency. ISMP Medication Safety Alert–Acute Care. 2002; 7: 1-2 Google Scholar The challenge in many departments is to bring awareness to the risk that is inherent in our everyday processes, motivate and energize the ED team to speak up when they recognize risk, and work to create improved processes and systems, making the emergency department more reliable in risk identification and the prevention of error. Susan Paparella, Member, Bux-Mont Chapter, is Vice President at the Institute for Safe Medication Practices (ISMP* *ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.*ISMP is a nonprofit organization that works closely with health care practitioners, consumers, hospitals, regulatory agencies, and professional organizations to educate caregivers about preventing medication errors. ISMP is the premier international resource on safe medication practices in health care institutions. If you would like to report medication errors to help others, E-mail us at: [email protected] or call (800)FAIL-SAF(e). This Medication Error Reporting Program keeps information confidential and secure. We will include only the level of detail that the reporter wishes in our publications.), Horsham, PA, and a member of the Advisory Committee for the Institute for Quality, Safety, and Injury Prevention.