Preventing Medical Errors: Pandemic Lessons Learned

The COVID-19 pandemic resulted in a surge in demand for health care, leading to widespread shortages of PPE, staffing, hospital beds, and more. During this time, the Institute for Safe Medication Practices (ISMP) issued a report that raised concerns about the alarming conditions, which one nurse described as ‘pandemic nursing,’ and which was increasing the risk for errors.

While many of these errors reared an ugly head much more frequently as the pandemic progressed, they are unfortunately all too common in a non-pandemic setting as well. The lessons learned over the past year and a half can, and should, result in the development of best practices that become standard at hospitals nationwide.

After all, medical errors have been estimated to be a third-leading cause of death. Remaining vigilant after the COVID-19 pandemic can help us fight this ongoing, silent pandemic.

Problem 1: Inadequate staffing and resources

Inadequate staffing and resources have added fuel to the fire and contributed to several reported errors. One problem, as the ISMP report notes, is that nurses often spent several hours in a patient’s room in isolation and so brought in everything they needed for that visit at one time. If they ended up with leftover medications or supplies, they often put them in a drawer or closet to use later.

Unfortunately, it’s all too easy to forget to bring something into a room initially, too. In many situations where that happened, it was common for a nurse to search those same drawers and closets to attempt to find what they needed. That increases the risk of giving the wrong medication or using the wrong type of medical device.

PPE shortages also meant nurses could only change gloves between patients and were in the same PPE for an entire shift, often sweating profusely which caused physical discomfort and added to the mental and physical fatigue.

Lessons learned

ISMP recommends involving pharmacy staff in safety huddles and discussing specific medication concerns with them.

They also recommend numerous solutions to help prevent medication errors, most of which are also best practices that should be continued long after the world has gained better control of COVID-19.

Simple solutions to help prevent errors include:

• Extra auxiliary labeling
• Different packaging (eg, syringe vs IV bag)
• Color-coding

ISMP also recommends:

• Standardizing to a single concentration of a high-risk infusion
• Standardizing the infusion rate and ensuring Smart Pumps are programmed as such
• For common infusions, using premixed, commercially available solutions that look different
• Clearly labeling all IV lines between the smart pump and the source container
• Establishing a process for conducting independent double checks before critical infusions
• Conducting daily safety huddles with doctors, nurses, and pharmacists

Problem 2: Stress and culture

The high volume of patients during the pandemic, combined with strained resources and difficulty in maintaining standards of practice, have all contributed to stress and have strained the culture of safety. Errors have often gone unreported for fear of retribution.

One nurse interviewed by ISMP noted the critical care nurses were being given 2 seriously ill, ventilated patients and 1 recovering patient per shift, a far cry from the standard 1:1 nursing ratio of an ICU. Combine that with administration of multiple high-alert medications per patient and physical and emotional exhaustion and it creates an environment ripe for errors.

Lessons learned

Unfortunately, many of the solutions those same nurses suggested were falling on deaf ears, according to the ISMP report. Managers and leadership were frustrated by the frequency of errors and felt unable to do anything about it, so blame was turned on individual nurses, or if it was unclear who made the error, the nursing staff as a whole.

Some ways to reduce stress and promote a positive culture include:

Deference to expertise is a hallmark of high reliability organizations – seek solutions from those with the most experience, which in this case is frontline staff.

• Management and hospital leadership should take an active role in seeking opportunities for improvement.
• Management and hospital leadership should also lead in creating a “Just Culture” within the organization.
• Supporting frontline leaders, while holding them accountable, will help their department to do their best work.
• The Joint Commission and ISMP have published tips on supporting frontline staff.

Problem 3: Inexperience

Surges of COVID-19 patients flooding emergency departments and ICUs required not only more material resources but also more human resources. Unfortunately, there is no way to quickly scale up on experienced critical care staff.

Instead, some medical schools assigned early graduation to last-year medical students, offering them an internship or job at the hospital until their residency started, and retired doctors and nurses were brought back into practice. Doctors who had never practiced in critical care, like psychiatrists and ophthalmologists, were also being reassigned to the critical care setting.

These factors increased the risk for errors. In particular, a lack of experience with ventilator management was identified as a cause of errors in some cases. Add to that the initial absence of any treatment guidelines for COVID-19 because its cause was a novel virus, and you end up with a very challenging – and dangerous – health care environment.

Lessons learned

One hospital’s strategy to address inexperienced staff was to have experienced critical care physicians supervise larger teams of physicians and nurses less experienced with critical care. Doing so allowed them to maximize the amount of care they were able to safely provide.

A JAMA Viewpoint article, followed by an AMA interview with the authors, describes some potentially long-lasting effects of the COVID-19 pandemic on medical education, including:

• Exploring the possibility of earlier graduation of medical students
• Expanding public health education in medical schools, which could help with other public health crises, like the opioid epidemic or disparities in health care
• Shifting medical school education philosophy from one of knowledge to one of problem solving.