Preventable errors

September 4, 2006 -- Judy Foreman's "Health Sense" column, published today in the Boston Globe and syndicated nationwide, focused on ways to prevent medication errors. "Be sure those pills you're given are the right ones" contains valuable information about how patients and health workers can work to reduce errors. The piece refers in passing to the fact that nurses give and can help to explain medications to patients. But it cites no nursing experts, relying instead on four different physician sources. And it misses the key role nurses play in catching most medication errors--a role that calls upon nurses to be critical thinkers and advocates, not just people who mechanically implement the plans of others, as the piece's description implies. The piece also ignores the extent to which the nursing shortage and the general undervaluation of nursing hampers efforts to reduce drug errors. Short-staffed nurses are less able to catch the errors, detect changes in patient conditions, and provide other care that enables drugs to work safely and well. Underpowered nurses have a harder time advocating for changes in medication plans and medication administration systems. And the piece repeatedly suggests that only "doctors" prescribe drugs, even though most of the over 200,000 U.S. advanced practice nurses regularly do so as well.

The piece notes that a recent Institute of Medicine (IOM) report found that more than 1.5 million people are harmed by medication errors in the U.S. each year, mistakes that cost more than $3.5 billion to treat. The average hospital patient has one such error each day. The article notes that IOM has recommended a number of systemic changes to reduce errors, including electronic prescription systems, and improving drug information and labeling. The piece recommends that consumers make a list of all their medications to keep "doctors" from prescribing inappropriate drugs, pay attention each time a nurse gives a medication in a hospital, keep track of hospitalized patients' liver and kidney function, and make sure they understand the drugs they'll be taking after hospital discharge and following a visit to "the doctor's office." Patients can also encourage systemic reforms themselves. They can push hospitals to track their medication errors, and to make sure each drug given is "ordered by a doctor on a computer," which can help reduce dangerous interactions and allergic reactions. Indeed, the piece reports that in one large Michigan practice, "physicians caught 98,000 potentially harmful drug errors before they happened" in the first year and a half of "e-prescribing." These are all sensible ideas.

The piece acknowledges that nurses give medications and have some understanding of them. It notes that hospital "[n]urses should match not just your name but your birth date and patient ID number with the information on the medication order." The piece also advises patients to go over the list of prescribed drugs with a "nurse or doctor" at the time of hospital discharge, and to get a written explanation of any newly prescribed drug from a "nurse or doctor" at the "doctor's office."

But the piece ignores the active role nurses play in preventing errors, and the extent to which they could do more with better working conditions. The vision of nurses the piece presents is that of people who have enough understanding of the drugs they're giving to explain why a patient is getting them, but who give what physicians prescribe without using any independent knowledge base or critical thinking to determine whether it's a good idea.

In fact, nurses catch most of the medication errors that are caught in hospitals. It is a core nursing mission to protect patients from harm, and nurses use their years of college-level health education to do that. Nurses are obligated by their independent legal and ethical duties to assess all drugs they are asked to give, and if they believe the drugs are not in the patient's best interests, to advocate for better ones. Likewise, nurses monitor patients carefully for adverse reactions, and they spot many problems that way. Of course, a short-staffed nurse is far less able to perform these key functions, and so a critical way to reduce errors is to ensure adequate nurse staffing. Indeed, a short-staffed nurse is understandably more likely to make a dangerous error herself, even if there is no problem with the prescription. Other challenges include the qualification of the person giving the drugs, who in some cases is not a fully trained nurse, and relations among the staff--atmospheres in which disruptive or imperious physician conduct is tolerated are more likely to experience errors because other staff are less able to prevent them.

The piece says that "family members and doctors" should monitor hospital patients' kidney and liver function because "lying in bed for several days reduces blood flow" and can make otherwise safe drugs dangerous. But nurses are central to this monitoring, and it is also nurses' job to get patients out of bed so that their blood flow is adequate to handle the drugs. Of course, nurses can't prevent such complications if they don't have time.

A big part of the reason that even elite media pieces often ignore the central role nurses play in reducing medication errors is the general invisibility of nurses' work, and the tendency to credit physicians for it. It is evident that pieces like this one assume that physicians direct all health care, and that nurses act only on physicians' behalf, rather than pursuant to autonomous professional duties. Prevailing clinical dynamics have helped to create the illusion that physicians do everything of importance with regard to medications. As Suzanne Gordon has explained, when a nurse catches an error, he typically tells a physician or other practitioner, and the patient then sees that practitioner as being solely responsible for the resulting change. Sometimes a nurse has to argue strongly for such a change, but it is rare that the nurse gets credit for it. Media pieces like this reinforce these misimpressions, especially when the pieces rely heavily on physicians for expert comment, but ignore the nurses who actually give the medications, as well as the advanced practice nurses who prescribe an increasing number of the medications.

We thank Ms. Foreman for her attention to medication errors, but we hope that in the future she will consider the vital role nurses play in preventing those errors.

See the article "Be sure those pills you're given are the right ones" in the September 4, 2006 edition of the Boston Globe.

Please send Ms Foreman your comments at foreman@globe.com and please copy us on the letter at letters@truthaboutnursing.org