Home E-Weekly January 21, 2014

A Novel Way to Prevent Medication Errors

Published: January 20, 2014

Short video accounts of actual medication errors portray the seriousness of drug-related mishaps and the everyday risk factors that contribute to the mistakes, according to research conducted at the University of Texas MD Anderson Cancer Center in Houston.

Patrick Sayer Monroe, PharmD, a medication safety consultant at the facility, decided to produce videos when an in-house survey revealed the important details of errors were shared on a unit-by-unit basis, but not effectively communicated across the facility, says a published report in Pain Medicine News.

A multidisciplinary team comprised of a pharmacist, nurse and patient safety specialist review monthly errors to identify examples of medication safety gaps, from which another team of pharmacists and mid-level providers pick topics to turn into video presentations. The facility's communications department then writes scripts, organizes re-enactments and produces the videos, which are integrated into PowerPoint presentations for staff meetings and posted on the facility's intranet.

According to Dr. Monroe's pilot study, hospital leaders accessed the facility's 8 online videos approximately 3,500 times between October 2012 and June 2013, and 83% of those who accessed the videos showed them during staff meetings or daily team huddles. Many of these leaders described the videos as "very" or "extremely" helpful in sharing medication safety information, and most of the front-line staff claimed the presentations kept them from committing similar errors.

Dr. Monroe concedes that the videos are time-consuming to produce and raise concerns about the security of the potentially sensitive material they depict. But he insists the benefits of telling the stories behind medication errors are long lasting and valuable for repeated educational applications. In fact, MD Anderson Cancer Center has started to produce videos aimed at preventing other types of care-related errors.

Daniel Cook

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