/publications/issue/2002/2002-11/2002-11-7013

Mental Errors in the Pharmacy

Author: Kate Kelly, PharmD, Editor, ISMP Medication Safety Alert! Community/Ambulatory Care Edition, and Allen J. Vaida, PharmD, FASHP, Executive Director, Institute for Safe Medication Practices

Today, it is widely recognized that system failures cause errors and well-designed systems that employ technology where appropriate and are used correctly offer the best chance of preventing errors. Yet, has the growing focus on systems and technology caused people to overlook other interventions? Has enough attention been paid to understanding how the human mind operates and the conditions that adversely affect its function, resulting in errors? Has enough been done to identify stress-producing aspects of complex systems such as a pharmacy and steps to help people cope with them? Has consideration been given to how personal beliefs, values, and attitudes influence performance?

Tony Grasha, PhD, professor of psychology at the University of Cin-cinnati, Cincinnati, Ohio, has studied cognitive functions and psychosocial factors that impact the accuracy of outpatient pharmacists.(1)An overview of his research, including specific interventions, follows.

Periodic Self-Monitoring and Deferred Verification
Errors were reduced by 21% when pharmacists periodically monitored themselves to detect errors. Each subsequent check identified 95% of errors that were missed during a prior check. However, mistakes were detected less frequently as the amount of continuous time spent on the specific activity increased. Thus, taking a short break or changing to a different task before self-monitoring increases effectiveness.

Light and Magnification
Errors were reduced by 16% when pharmacists were given a high-intensity task light and a magnification lens to read prescriptions.

Copyholders
Errors were reduced by 24% after installing a device to hold prescriptions on the computer monitor, closer to eye level, to improve the visual angle during order entry.

Alerts
Posting alerts in strategic locations for 30 error-prone products reduced errors with these products by 71% and reduced potentially significant occurrences by 45%. Errors with nontarget-ed drugs also were reduced by 56%, simply through heightened error awareness.

Exaggerated Product Labels
Errors were reduced by 35% after affixing product sleeves with exaggerated, nonconventional type fonts to ?better-read? sections of drug names or doses.

Cognitive Style and Coping Skills
Pharmacists who were able to attend to details and focus their attention made fewer errors. Approximately 12% of pharmacists had difficulty with details and focus, and these pharmacists produced 33% of all the mistakes observed. High-intensity lights, copyholders, and exaggerated product labels were especially helpful for such individuals. Pharmacists with adequate coping skills and stress management training also made fewer errors.

Workload
Pharmacists were more vulnerable to mistakes under low workload conditions and when shifting from high to low activity. Boredom, reduced task focus, and disruptions in personal work rhythms made it hard to focus on tasks, even though pharmacists with both low and high workloads were equally concerned about their performance and were motivated to do well.

Breaks
Pharmacists who perceived that break times were adequate and available made fewer errors and detected more errors during self-monitoring.

Supervision
Pharmacists who made fewer errors had supervisors who fostered appropriate autonomy and were perceived as being democratic, facilitative, and helpful in setting goals. Pharmacists who made more errors had supervisors who were perceived as overly autocratic and punitive. Supportive supervisors who interacted well with their staff members lowered stress levels and allowed staff to better focus on tasks at hand.

Feedback and Goal Setting
Pharmacists who received constructive feedback about errors from the research team, and who established goals to enhance error detection, were able to improve their ability to detect and prevent errors by 103%. After 2 weeks, pharmacists were asked to set a goal to either maintain their current performance or improve their ability to detect mistakes. Compared with a control group where no feedback was provided, even those who set a goal to maintain current performance increased error detection by 22%. Instead of comparing performance with that of others, establishing personal improvement goals, combined with constructive feedback about errors, proved quite beneficial. Interestingly, pharmacists ranked feedback and goal setting among the most effective strategies investigated by the researchers.

Although differences in specific facilities, processes, and individual makeup can influence the success of these interventions, they are widely applicable in a broad context. According to Dr. Grasha, ongoing understanding about how people react to systems and integrate them into their mental structures will enable experts to find new ways to enhance workflow, physical work spaces, sensory input, and memory; to identify new applications for technology; and to improve training for supervision, conflict resolution, and stress management. In the long run, such interventions will lead to increased professional satisfaction, workforce retention, enhanced efficiency and productivity, and improved patient care and safety.


Report Medication Errors
The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices (ISMP). ISMP is a nonprofit organization whose mission is to understand the causes of medication errors and to provide time-critical error-reduction strategies to the health care community, policy makers, and the public. Throughout this series, the underlying system causes of medication errors will be presented to help readers identify system changes that can strengthen the safety of their operation.

If you have encountered medication errors and would like to report them, you may call ISMP at 800-324-5723 (800-FAIL-SAFE) or USP at 800-233-7767 (800-23-ERROR). ISMP?s Web address is www.ismp.org.