1. Cohen, Hedy RN, BSN, MS

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In this issue, we report the results of our comprehensive survey on medication administration safety. (See Nursing2008 Survey Report: Getting to the Root of Medication Errors on page 39.) We were encouraged to learn that nurses seem to understand the complexity of the medication administration process better than they did in 2002, when we conducted a similar survey, and some complimented their facilities for safety initiatives. But many voiced serious criticisms of their facilities and the environments in which they function. One common theme: the use and abuse of error reporting systems.

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Some nurses commented that when they complete adverse event and near-miss reports, the reports end up in a black hole with no analysis of the cause. Even more disheartening was the news that some nurses are dissuaded from reporting at all unless a patient is harmed.


We were also disturbed to learn that in some facilities, event reports are still placed in nurses' employment files and used against them. More than one nurse mentioned that her pay was directly connected to the number of errors she reported.


The medication-use process is a continuum of complex, multistep measures involving many individuals. It functions effectively and safely only when hospital leaders reject the myth that human fallibility is the root cause of errors and accept responsibility for designing systems that attenuate human errors, which are inevitable.


Organizations should make safety their number one priority, even listing it in their mission statement. They must be committed to designing and enforcing protocols that break down "silo thinking" and improve teamwork among healthcare professionals. And individual practitioners must be willing to change their own habits.


What can you do? I recommend these strategies to help build a culture of safety:


* Read our survey results for a review of best practices and identify areas needing improvement in your unit or facility.


* Ask your facility's executive leaders to conduct walking rounds to listen to your concerns and ask for feedback.


* Request that a culture of safety survey be conducted and the results made transparent. Volunteer to be on the committee to analyze the data and initiate strategies for improvement. Frontline nurses like you should be on every committee that discusses any aspect of the medication-use process, including the purchase of medication technology.


* Join with physicians, pharmacists, and other nurses to improve the safe delivery of medications to patients in your unit. To cultivate communication and teamwork, have pharmacists shadow a nurse and nurses shadow a pharmacist for at least a day.



Let's work together to obliterate the myth that human error is the lone root of medication errors and implement changes that protect our patients from preventable harm.


Hedy Cohen, RN, BSN, MS


Vice President, Institute for Safe Medication Practices Horsham, Pa.