How to Prevent Medication Errors When Faced With the Pressures of Pandemic Care

A nurse cited in a recent feature article at the Institute for Safe Medication Practices (ISMP) may have coined a new phrase: “pandemic nursing.” It’s exactly what you’d guess. He describes pandemic nursing as the “rushed, physically overwhelming and emotionally draining care provided to an onslaught of crucially ill patients,” and as he reports, it’s leading to serious medication errors.

Physicians and other frontline providers also know the hectic pace of pandemic care and its inherent risks. Like the nurse in the ISMP story, they understand what it’s like to be “exhausted and overwhelmed and sweating profusely under the PPE.” They recognize the scenarios laid out by ISMP – perfect storms of “under-resourced healthcare environment,” “criticality of patients” and “unimaginable anxiety” – and see how these factors can contribute to errors.

As COVID-19 continues to surge across the country – and as states like New York try to learn from previous outbreaks –ISMP says it’s critical “to aspire to identify and prevent errors and to avoid blaming attitudes when medication errors happen.”

Specifically, ISMP recommends the following:

Identifying medication errors – “During the pandemic, it is advisable to create a streamlined reporting process and build informal reporting pathways that promote communication and feedback, such as daily safety huddles.”

Preventing medication errors – Take steps, “even during a surge, to minimize the risk of concentration errors, programming errors, titration errors and other mix-ups among IV infusions.” For example, standardize dose-rates for specific IV infusions, improve labeling and determine when double checks may be helpful.

Avoiding blaming attitudes – “Blaming and shaming is neither a noble nor productive way to reduce errors—the opposite is true, as we have abundantly learned in healthcare. Leaders and managers should set a good example and support workers through the turmoil of the pandemic.”

In its summary of the ISMP recommendations, Becker’s Hospital Review offers this reminder: “Surges in COVID-19 patient volume place significant physical and emotional demands on clinicians, which can lead to an onslaught of preventable medication errors.”

Policyholders are encouraged to check out the Becker’s and ISMP articles in full – both offer extensive information beyond what’s cited here – and to visit our dedicated resource page for ongoing guidance related to delivering care during the pandemic.  

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