Grantee Profiles
Linda Flynn
Linda Flynn, RN, Ph.D., Project Director and Principal Investigator, Medication Safety Initiative
Each year, 7,000 people die because of medication errors in hospitals. INQRI researcher Linda Flynn, RN, Ph.D., is trying to find out why, and what processes need to improve to prevent medication errors from occurring. Flynn and her multi-disciplinary team at the New Jersey Collaborating Center for Nursing at Rutgers University's College of Nursing, are examining how the practice environment and the level of nurse staffing affect medication errors. "This is the first study I know of that tries to show how predictive those two things are," she says.
According to the Institute of Medicine, in hospitals, errors can happen throughout every step of the medication process but occur most frequently during the prescribing and administering stages. In a 2006 report, IOM warned that a hospital patient can expect to be subjected to at least one medication error each day. Although the frequency of medication errors has been well- documented, there is little study of what the root causes of these errors are or the actual cost. Flynn says some estimate that medication errors cost hospitals about $2 billion a year nationally. However, most of the costs are attributable to known "injury" to patients. The research she and her team are conducting hopes to shed light on the "hidden" costs of medication errors even if they don't result in direct harm such as the potential costs associated with responding to the error via additional lab work or the added length of stay for a hospital patient as a result of a medication error.
Flynn is hoping to offer answers to questions about the cost and implications of medication errors by examining work environments and nursing staff situations in 14 hospitals in New Jersey encompassing 85 medical or surgical units. Identifying the link between nurses and better care is critically important, she says, because hospitals need solid evidence before they will change a practice environment. "The nurse is the last person that has the opportunity to prevent an error. They are the last line of defense, the final safety net," she says. "If we can identify what helps nurses catch medication errors and what steps they take to identify an error before it happens, these would be important steps toward protecting patients."
The INQRI-funded Medication Safety Initiative hopes to show what best practices nurses employ to intercept medication errors in the hospital. In the project's first phase, Flynn and her team created a "medication safety process scale," a tool to measure the degree to which nurses engage in specific practices to avert errors. Flynn and her team developed the tool from intensive, one-on-one interviews of 50 RNs in 10 hospitals. Researchers asked nurses to identify barriers to preventing medication errors, what helped them catch medication errors, and what they did to identify and intercept an error.
Based on the survey responses, Flynn's team identified 7 routine steps nurses take to make sure medication errors don't happen.
- Nurses conduct independent medication reconciliation. Nurses at the beginning of a shift go back to the patient's medical record and look directly at the orders that a physician has written and check them against their own records. They call this a "super double check."
- Nurses ask questions. They ask why a patient is getting a particularly medication or whether there anything going on today that would conflict with the medications being ordered.
- Nurses discuss medications with physicians. They ask physicians why they have changed a particular course of treatment such as why a pain medication has been increased. They don't take at face value what the doctor has ordered.
- Nurses educate patients and families. They teach patients about their medication and explain the therapy to the family. They educate patients or family members to make sure they understand why they have been prescribed a medication, and what they are taking. This enables them to also question the nurse if they feel something is wrong.
- Nurses advocate for patients. When medications are delayed, nurses work with the hospital pharmacy to make sure patients are given medications as scheduled to avert delays that could trigger problems.
- Nurses Seek Clarity. They ask physicians to rewrite or clarify an order if they can't read their handwriting.
- Nurses fully assess the patient. Nurses conduct careful assessments of the patient's status to make sure the medication is appropriate at the time.
Flynn is now using the scale to see whether these practices make a difference and are predictive of medication errors. "We are trying to show how nurses can be instrumental in catching errors before they reach the patient and what nurses do to prevent errors from happening." She also is looking at the implications for safety of units with more RNs, better collaboration with pharmacies, and supportive work environments. She plans to have those results to report at INQRI's July meeting in Princeton.
Flynn says the study has illuminated the challenges nurses face every day in keeping patients safe from medication errors. She recounts how often nurses are needlessly interrupted when they are trying to reconcile patient medications. She has witnessed firsthand nurses having to answer phone calls from the lab for a non-emergency when they are in the middle of counting pills, or having to stop what they are doing to reconcile medications to respond to a patient's family member seeking a drink of juice for their loved one.
Flynn recounts how one nurse, unable to find a quiet place to focus on her task, simply sat in the middle of a chaotic medical unit hallway to reconcile medications for her patient panel. Flynn observed that the nurse was interrupted every 45 seconds for tasks that could have easily been done by others on staff or could have waited until she finished. These are the kinds of interruptions that can lead to medication errors, she warns.
Flynn says hospitals need to foster work environments that let nurses focus on safety efforts without the fear of being needlessly interrupted. "Hospital systems are not designed in a way to keep patients safe. Nurses are just out in the open and subject to constant stimuli."
The good news, says Flynn, is the INQRI research is showing that "all of these things we are looking at are modifiable. If nurse staffing is a predictor of medication errors, we can do something about that. Hospitals can staff better or they can look at what nurses are being asked to do and take extraneous activities away and assign them to others."