the development of hospital ethics review board policy for medication error: by the process of...

8/8/2019 The Development of Hospital Ethics Review Board Policy for Medication Error: By the Process of Examination

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The Development of Hospital Ethics Review Board Policy for

Medication Error: By the Process of Examination

A POSITION PAPER By

Morgan La Femina

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0Unported License.



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Abstract

Errors along the medication distribution process occur from the doctor/prescription

writing stage to the nurse/dispensing stage the most medication errors occurring at both the

beginning and at the end of the process (Aspden, Wolcott &Cronenwett, 2007). The medication

error rate is estimated at 11 % of all doses administered, not including time shifts in the

administering of patient medications. The potential for this rate to increase if there are no

proactive solutions in dispensing, culture, automation, ethics, and reporting is extensive.

Improvements in health care will follow system redesigns, but along with these improvements

come new difficulties such as adverse medical events and prescription errors (Kohn, Corrigan

&Donalson, 2000). Mandatory reporting is seen as a method to reduce errors because it is seen as

forcing clinicians to be accountable, these error reports are generated by computer systems.

There is no standardized computer system for reporting with several types carried out. Some

systems are voluntary and in others, reporting is mandatory, some report on all adverse effects

and some are specialized for only medication errors depending on the state (Aspden et al., 2007).

Medication error is primarily considered a pharmacy process, with the burden of most of the

mistakes occurring during the administration of the medication to the patient. Nurses are

clinically charged with administering medication and so most of these mistakes occur by nurses.

However, the complexity of today's health care settings, the culture within a hospital, the high

workload of nurses, and the question of reporting at all are all potential root causes of medication

error (Meany, 2004).



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Nursing associations have voiced concern of when to report an error, how to decide if the

error should be reported, and of a culture of blame that shifts the fault automatically to them

(Hohenhaus, 2008). The lack of clinician support for nurses is a considerable focus for all those

intent on reducing medication errors such as administrators, hospital boards, hospital ethics

boards, regulatory agencies, and hospital IT technical staff. Support for nurses is fundamental

because this neglect is seen as another reason why medication errors are so high. Differing

standards are seen to exist with errors based on whether the staff person was a nurse or a

physician. Physician standards on errors appeared to be slanted in favor of the physicians while

blame was perceived to be greater for nurses by the nurses (Hohenhaus, 2008). Derisive culture

can be between departments and different among them. Organizational roles can create blame

among clinicians, which can prevent error reporting thought fear of punishment or scorn

(Meaney, 2004). Culture is a huge factor in hospitals and a barrier to reporting. Holistic values

driven hospital can be shown to have clear clinical value statistically (Hensing, Dahlen, Warden

et al., 2008;Aspden et al., 2007).



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Table of Contents

Title PageAbstractAcknowledgmentsTable of ContentsList of TablesList of FiguresChapters

Chapter 1-Introduction

The Statement of the Problem

General Background for the Study

Chapter 2-Literature Review

Review of Literature

Medication Error Levels in Hospitals

The Lack of Clinician Support in the Reporting of Medication Errors

Modeling and Modification to Prescription Workflows

Automated hospital Medication Processes

Chapter 3-Public Policy

Policy, ethics and how they can affect the severity of errors, the lack of support,the modeling of prescription workflows and the understanding of automatedmedication processes

Ethical Constructs

The unification of ethics and EHR systems

The unification of an ethics based approach to EHR and error reporting

Chapter 4-Conclusions

The practice of Nursing, medication error and trust in error reporting

An ethics based model of reporting error

Bibliography



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Chapter 1-Introduction

The Statement of the Problem

A federal mandatory reporting policy for medication errors should be enforced at every

hospital. This policy should be ethics based so that doctors or nurses reporting medication errors

patient remain anonymous until a given level of severity is reached. Although mandatory

reporting is advocated in this case history, this paper outlines conditions which keep reporting

safe, secure and practical for both the reporter and the patient. This collective case study is

important because hospital medication errors are rising in number and severity, causing injury,

death and liability. Without a consistent, practical to carry out, federal medication error reporting

policy: 1. Error reporting will continue to be critically low 2. The fear of personal penalties will

continue to prevent reporting 3. The personal time and effort taken to report will be seen by

doctors and nurses as useless 4. Hospital policy review boards will continue in their lack of effort

to support reporting.

Hospitals form the backbone of health care in America, whether it is of first or last resort for

the patient in need. They offer emergency treatment for those who need it and provide advanced

tertiary care, or care requiring multiple systems and in patient procedures to become well.

Hospitals are at the forefront in medical advancements, which cure patients. Hospitals require

teams of doctors, nurses, pharmacists, administrators, and technicians to provide the services the

public has come to expect and need. Hospitals unlike any other type of medical facility specialize

in coordinated health care for the person. This coordinated care requires information and orders

to flow efficiently from doctors to nurses for them to practice quality medical care. Nevertheless,



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with all this coordination comes complexity, with this complexity comes with the opportunity to

make mistakes.

A mistake, according to the Merriam-Webster dictionary online is, ³to identify wrongly:

confuse with another´ while the definition of a hazard is, ³a source of danger´ (³mistake,´ 2010).

The complex exchange of information by the many clinicians in a hospital creates a source of

danger where medications are confused with each other (³mistake,´ 2010). Medication errors are

a chain of events, where the error often originates before the actual event. The error occurs when

the mistake is transferred from the practitioner to the patient. Potential mortality and liability

from a medication error create a need for the reporting of medication error events. The reporting

of adverse medical events or medication errors has two positive outcomes: 1. It creates

accountability 2. It provides the information of how and when the error occurred. With this

information, statistical models can be created, which can be used to redesign the medication

delivery and dispensing process, reducing points where mistakes can happen.

Accountability by the self-reporting of errors means that nurses, doctors and other clinicians

can strive for greater accuracy in the filling and distribution of prescriptions. However, the

liability of reporting and the potential for the clinician to be discharged from employment for an

error they made can be so great that this suppresses their likelihood of reporting. This potential

suppression creates four issues. 1. There is a lack of reporting so complete and fully accurate

models of how medications move through the hospital system is lacking. 2. Without accurate

models of how medications move through a hospital system, researchers cannot determine in

detail how to refine the medication process so less medication errors occur. 3. The clinician must

deal with is the definition of what makes up an error, when to report an error and how to report

the error. The last issue that must be resolved is that of clinician anonymity. There must be the



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assurance that if a clinician reports an error,her anonymity will be secured and would only be

revealed if the error she committed were severe enough that her identity must be known to the

official reporting agency involved.

If the above listed issues on medication error reporting are resolved, reporting will increase

leading to more accurate research on medication errors with the potential result of better

medication workflow models. These newer medication models become new systems to be

installed in a hospital replacing the older less accurate systems. Better medication workflow

models will have the result of reducing medication errors system wide. However, this can only

happen if more error reporting occurs. More reporting can only happen if health care workers

know when, why and how these errors occur. This can only happen if a policy framework is

developed, whereby clinicians and hospital management have a workable ethical model, one that

guides clinicians and managers through all the what/if decisions when medication errors occur.

In order to develop a reasonable framework for error reporting we must understand how

medication errors occur and how information is exchanged among clinicians. To facilitate this

understanding we must understand the current hospital IT workflow process.



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General Background for the Study

Health care organizations did not exist until the 1930's when Blue-Cross Blue-Shield

provided a method for reimbursing hospitals for patient services through the depression era

(Getzen, 2007). Before this time health management pioneers such as Dr. Michael Shadid, Dr.

Donald Ross, Clifford Loos, Dr. Sidnet Garfield and Henry Kaiser sought to provide

comprehensive health coverage to the patient at a reasonable price (Allen & Krasner, 2009). At

that time, the method of payment for health care services was a standard fee for service, although

this method was funded primarily by prepayment by the patient into a medical savings account

(Allen & Krasner, 2009). In 1929 with a growing concern that people needed a way to pay for

medical coverage beyond cash in hand, Baylor Hospital decided to offer a hospital pre-payment

plan for the local teachers association (Getzen, 2007). Those teachers that enrolled under the

Baylor hospital pre-payment plan could get services at the Baylor hospital; however, the plan did

not cover services at other hospitals (Getzen, 2007). In time, other hospitals began to join them

under the state¶s hospital association thus unifying coverage and the health maintenance

organization Blue Cross was created (Getzen, 2007).

During World War II a few other health plans began to emerge, such as Group Health

Association in Washington DC as well as The Health Insurance Plan of NY along with Henry

Kaisers, Kaiser Permanente (Allen & Krasner, 2009). Through the late 1940's employee health

insurance became the standard model by which patients begin to pay their medical bills

(Enthoven, 1993). Offering employee health insurance became a primary method of attracting

employees because it was an inexpensive benefit (Enthoven, 1993). A second reason employer¶s

began offering health insurance coverage was because of World War II itself. During World War

II employers were barred from raising wages, employers needed to attract good employees and



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offering health coverage was one of these methods (Getzen, 2007). With most employers based

health insurance, employers must pay a fixed amount toward the employee benefits, even if the

employee has not used any health services (Getzen, 2007). Because providing health care

originally was inexpensive health care providers, health care insurers and patients did not need to

worry about costs, thus consumption drove prices higher (Getzen, 2007). Employers and

employees had to pay fixed causes regardless of consumption so use of services was a ³use it or

lose it´ benefit and employees took advantage of the use it or lose it philosophy (Getzen, 2007).

Consumption of health care resources began to outpace the supply of them and as costs

skyrocketed health insures then sought to control those costs. Health insurers, employers,

Medicare and Medicaid payments over time were forced to adjust their billing methods to control

expenditures (Getzen, 2007).

In the book Health Economics and Financing, the author Thomas Getzen writes that the

relative freedom that doctors and hospitals had to perform and bill was replaced by a much more

ridged oversight and price control structure (Getzen, 2007). In 1983, the prospective payment

system for Medicare and Medicaid replaced the previous reimbursement process (Getzen, 2007;

The Henry J. Kaiser Family Foundation, 2009a, The Henry J. Kaiser Family Foundation, 2009b).

The new prospective payment system provided health care facilities reimbursements based on

diagnosis related groups or DRG¶s (Henry J. Kaiser Family Foundation, 2009a). What was

significant about the new DRG¶s was that reimbursements for procedures were set at pre-

determined amounts without taking into account any other costs (Henry J. Kaiser Family

Foundation, 2009a). In 1985, these reimbursement levels were capped for inpatient hospital care

(Henry J. Kaiser Family Foundation, 2009a). In 1989 limits to balance billing were enacted

(Henry J. Kaiser Family Foundation, 2009a) further limiting the ability of hospitals and doctors



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billing flexibility to cover extraneous costs incurred when providing health care services.

Medicare and Medicaid adopted the ICD-9-DM and ICD-10-DM coding structure which unlike

the fee for service billing methods before paid standardized rates, which were considered usually

and customary (Mitchell, 2007). During the late 1970's and early 1980's health maintenance

organizations or HMO¶s, and employee/employer began to adopt the ICMS-9 codes that

Medicare and Medicaid had implemented years earlier (AMA, 2006). They did this in large part

because the IDC-9-CM code simplicity and the cost savings involved with the way Medicare and

Medicaid billed using IDC-9-CM codes (AMA, 2006).

Medicare and Medicaid began to cut payment schedules as part of the budget reconciliation

act during the early 1980¶s; this coupled with the surge in HMO contracting with health care

customers, caused a defensive reaction by Hospitals and other health care facilities (Getzen,

2007). Mergers of health care insurer¶s began to exercise their market advantage and cut

reimbursement rates to hospitals (Getzen, 2007). Hospitals and other health care agencies did not

cut the amount of services they provided to compensate for their reduction in total income

(Getzen, 2007). Hospitals were however able to bend services to meet contractual obligations

and still receive the same amount of revenue (Getzen, 2007). Physicians viewed these payment

cutbacks, the bundling of services into single payments and new more aggressive management

techniques by HMO¶s as a threat to their ability to be autonomous (Getzen, 2007). This set off a

wave of hospital mergers and hospitals joining with other health care facilities such as clinics

and outpatient firms to broaden their reach and protect what they viewed now as compromised

revenue streams (Getzen, 2007).

The waves of new medications, life saving machines and the rising costs of health care

premiums that employees and privately insured individuals now had to pay in the late 1980's,



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forced a poor mix of ever newer technologies with ever sicker patients (AMA, 2006). The

quantity of Medicare patients increased, but so too it became less profitable to treat them

(Getzen, 2007). This was because fewer people could afford an employer based health care

insurance and so either had qualified for the lower paying Medicare or Medicaid insurances or

went without insurance all together (Caffarini, 2009). In both cases, the persons admitted to

hospitals were sicker, required more time in the hospital, greater technology to become better

and a greater number of doctors and nurses to have them stabilized (Brewster, Rudell& Cara,

2001). This was because many were poorer, which was why they qualified for Medicaid, were

older, which would be why they could qualify for Medicare, or failed to go to the doctor when

needed because they lacked any insurance at all (Brewster et al., 2001).

Poor payment schedules and the increase population of elderly baby-boomers helped create

ever-rising hospital visits with either the same or fewer hospital bed numbers to place patients in,

partly due to the previous hospital mergers. During the 1990¶s staff shortages began to occur

(AMA, 2006) in part because of hospital inabilities to pay for a staff size large enough to treat all

the patients they see adequately (Getzen, 2007). This shortage continues into today. The AMA

estimates that in the next 15 years, because of the retiring of baby-boomers and the reduction in

hospital payment rates, there will be a shortage of up to 100,000 doctors and nurses in the next

15 years with which to treat them (AMA, 2006). This back history eventually combined to form

hospital systems where large numbers of very sick patients entered but a lack of physicians

whom could treat them properly (Brewster et al, 2006). Compounding this shortage of

professionals is a lack of funds with which hospitals could use to rectify these issues (Brewster et

al., 2001). Most expenses are in the form of labor costs, thus when revenue declines cutting jobs

must happen (Getzen, 2007). Of course, cutting physician jobs is politically unpopular (Getzen,



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2007). Charitable cases hospital treatment was previously paid for with Medicare funding, but

with Medicare¶s prospective payment cutbacks little general hospital revenue was left to treat

them Getzen, 2007). These circumstances left inner city hospitals with no ability to cost shift for

the poor and needy that law mandated them to treat regardless of their means to pay (Getzen,

2007). The only means of cost shifting then is to cut staff and services.

Unfortunately, the lowering of health care service reimbursements has accelerated since 2004

(Mortland, 2006). Tufts a teaching hospital in Massachusetts has lost 25 million treating Blue

Cross patients in from 2005 to 2009 (Allen & Krasner, 2009). Medicare and Medicaid rates for

health care services have been reducedeven further in part because of unprecedented state and

federal deficits (Caffarini, 2009). There are fewer donations to hospitals and most hospitals have

a large amount of floating bond debt, which has proven difficult to restructure (Caffarini, 2009).

At the same time, there are ever increasing levels of uninsured patients seeking care at hospitals

(Caffarini, 2009). Shortfall budgets have pressed hospital staffs even harder recently. In 2008,

107 hospitals had cut 50 or more employees at a single point in time (Caffarini, 2009). Half of all

736 hospitals surveyed that year were considering staff cuts (Caffarini, 2009). Lack of discharge

options for the very sick, who need long-term care compounded hospital overcrowding and the

ability to care for those patients (Brewster et al., 2001). Regulatory agencies do take notice of the

quality of health care service that is provided to hospitals patients with fines given as necessary

(Kohn et al., 2000). Many of these regulatory agencies in the past have used fines to urge

movement on the reduction of medication errors, but apparently this approach is not reducing

errors overall (Kohn et al., 2000). Stringent oversight has however improved patient care overall

though (Kohn et al., 2000). Now these regulatory agencies are seeking new ways to reduce these

errors beyond the standard of strict penalties.



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Research in health care technology and clinician communication can help bring the changes

needed to reduce errors, but only if enough data is available. For medication errors, the data to

study is drawn from the types and the frequencies of errors within a hospital and within the

national system studied. Without an enough data to analyze researched results will be inaccurate,

as well as the policies developed from them. Greater accuracy comes from a greater amount of

errors reported and this will only come from those doctors and nurses who will feel comfortable

enough to admit an error without fear of losing their carrier over it.



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Chapter 2- Literature Review

The practice of medicine in our health care facilities has seen extensive technological

advances in the last several years. Unprecedented advances in saving lives are causing prominent

ethical cases to surface (Mappes&Degrazia, 2001). In many of these cases, technology has

advanced without a body of ethical history to refer to. These technologies force decisions to be

made that have never been dealt with, the social tools need to answer them have not been

developed yet. We must create those social tools and use them in such situations before irrational

or easily influenced feeling are transferred into new policies that are counter-productive.

Counter-productive policies have been the result in cases involving medication error reporting, in

cases where error reporting is needed to acknowledge consumer rights and in cases involving

informed consent. This researcher will attempt to develop a map for health care administrators.

This map will offer a means to allow errors which if significant enough authorize the revealing

of the person who reported the error but if not significant enough to hide the reporters identity.

This paper attempts to review all the facts of error reporting before applying moral principles to

the case. After we have observed all the facts of a case, then ethics can be applied through moral

principles, used in an impartial way (Rachels, 1999).

Many theories that have been developed and the research it entails are called medical ethics

(Mappes&Degrazia, 2001). According to Thomas Mappes and David Degrazia, in their book

Biomedical Ethics 5th

Edition, ³An ethical theory provides a framework that can be used to

decide what is right and morally what is wrong, regarding human action in general, or what is

morally good and morally bad regarding human character in general´ (pg. 4). In essence, much

of what moral ethical thinking consists of is understanding the difference between what is a good

or what is a bad argument for setting forth to carry out a certain task (Rachels, 1999). This author



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also assumes that normative ethics can be used in situ within the field, at hospitals when errors

occur by doctors and nurses. It is also assumed by this researcher that an ethical framework can

be used to design a reporting mechanism for clinicians to use and that once these ethical

boundaries are put in place error reporting will increase. This researcher assumes that trust is

built on personal experience and personal impressions of the face.

Unfortunately, the experiences clinicians have faced with reporting errors have created

distain for error reporting. The experiences must change to alter nurse¶s perceptions about error

reporting and the impression of what their experience will be when they report an error. Laws

should not be passed on error reporting without first utilizing medical ethics in the health care

field. This increase in error reporting will occur if clinicians have trust in the error reporting

process. This increase in the reporting of medication errors will also give researchers in the fields

of engineering to have greater numbers of raw error data to work with. It is assumed that a

greater quantity of reports provided will better show the true quantity and diversity of what is

occurring in health care facilities. Finally, this researcher assumes that with error reports that are

more detailed, engineers can design higher quality medication workflow-models which will

lower the rates of medication errors in hospitals.

This researcher will use ethics based morality to create an ethical framework for medication

error reporting. This framework will implement the conceptual theories of ethics such as

Hobbes¶s Social Contract, Feminism and Deontology, although others will be reviewed. Truth

must be built on trust and trust on reason. Morality and the perceptions of how it applies to us in

a situation is according to Rachels, ³An exercise in reason- the ideas that should come out on top

are the ones that have the best reasons on their sides´ (p xii). This paper attempts to put the best



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reasons forth about what is required of the clinician, the patient, the administrator and the policy

maker when a medication error does occur.



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Medication Error Levels in Hospitals

The Joint Commissions sentinel event report as of December 31, 2008 reported the most

common error was wrong-site surgery, 747 or 13.2 of the total 5632 reported that year to the

Commission. Fourth on the list was medication error, or 492 or 8.7% of the total sentinel events

reported that year (Joint Commission, 2008b). Unfortunately, the direct submitting of error

events to the Joint Commission compounds fear of reporting. Sixty-nine percent of all the

sentinel event outcomes reported that year resulted in patient death or 3977 cases (Joint

Commission, 2008b). Of the total 5632, documented events by the Joint Commission in 2008 a

total of 77% or 4339 were submitted directly to the Commission, while just 98 of 2% were

reviewed on site (Joint Commission, 2008b). Most of all, these sentinel events occurred in

general hospitals as opposed to specialty hospitals or health care clinics 67% of the time (Joint

Commission, 2008b). If most error reports are sent directly to the Joint Commission and those

errors most often reported included patient death as the outcome, fear of reporting may have

resulted in the total reported cases being so low for the Joint Commission. This fear could have

been the reason why other reporting systems are utilized more heavily than the Joint

Commissions. Nurses are charged with the duty of administering medication and so most of the

apparent mistakes would occur by nurses (Aspen, 2007). However, the complexity of today¶s

health care settings, the culture within a hospital, and heavy workload of nurses are all potential

root causes of medication error (Aspen, 2007). Unfortunately, these reasons why errors occur are

not included in the reporting process (Aspen, 2007).

The tort system is used to correct the perceived negligence of clinicians and tends to suppress

the required information about how the error happened, due to its punitive nature. This



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information is needed to design better health care facilities and health care technologies to reduce

errors in the future (Joint Commission, 2005a). Pharmacists provide a critical gatekeeper role in

preventing errors after prescriptions have been sent from the doctor who has prescribed it. It is

estimated that over 60 million pharmacist interventions, which are changes in the type or dosage

of the medication prescribed by the doctor before it is sent to the nurse for dispensing, occur

every year in the United States (Kennedy, Littenberg et al. 2008). Re-designing the system of

medication flow through the hospital must occur for medication errors to decrease from the

levels they are at today. An objective understanding of this system is essential to providing a

foundation with which to build new models of how and when prescription errors occur (Bailey,

Engel et al. 2005). If there are no proactive solutions in dispensing, health care culture,

automation the potential for an increase in hospital facility errors is only going to grow.

The administration of medications to patients by nurses is only one part of the sequence of

medication events medications have to go through in a hospital. The IOM reports that up to 90%

of all medical errors are caused by the symptoms of failed systems and procedures within health

care facilities not the nurses themselves (Eldridge, 2005). However, nurses are the most visible

target of reprisals by the hospital and the patients when a significant medication error occurs

(Kohn et al., 2000; Joint Commission, 2005a). If actually compounded, dosage, timing, drug

quantity, the correct drug and the right person can mix to form a deadly result. These results only

occur when hidden system failures combine in the proper sequence to bypass safeguards and

latent errors become active affecting the patient (Aspden et al., 2007). Nurses, doctors and

pharmacists are potentially prone to error simply by being human (Nordenberg, 2000).

The majority of fatalities (96.8% of all deaths due to medication error) occur due to

overdose, having the wrong type of drug given to the patient and having a drug taken that was



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not ordered for the patient (Phillips, Jarvinen& Phillips, 2005). Just two factors wrong diagnosis

and wrong treatment have affected upwards of 40% of all patients who had experienced errors

(Aspden et al., 2007). According to the author Aspdenin his research article, Pr eventing

Medication E rr or s: Quality Chasm Ser ies,mistakes in medications comprised 28% of all

healthcare facility errors (Aspden et al., 2007). The rate of medication error and death if

compared to other industries, such as in manufacturing of industrial equipment is also high

(Natarajan&Hoffmeister, 2005). With the explosive growth in the variety and the strength of

medicines comes the greater potential for medical errors and death from these errors

(Nordenberg, 2000). Pamela Stanta, Michael Groves, and Leslie Pafford in a 1993 study

estimated 2,876 deaths from medication errors in primary care hospitals in the ten years

preceding the study. However, by 1993 the number in just that one year had grown to 7931

deaths by medication error (Bailey, Engel et al. 2005).

Nurses have complained about when to report an error and a culture of blame that shifts the

fault or errors automatically to them (Hohenhaus 2008). Health care practitioners fear the

potential loss of their carrier and the loss of reputation that medical liability lawsuits can cause

them (Joint Commission, 2005a). The fear of lawsuits creates silence among doctors and nurses.

With this silence comes the lack of error reporting. In 1986, the Joint Commission received 400

voluntary reports of patient deaths caused by medical errors, while the IOM estimates up to

44,000 to 98,000 deaths from medical error occur each year (Joint Commission, 2005a). In

contrast the very active New York State Patient Occurrence Reporting and Tracking System

logged more than 30,000 reports for all of 2003 (Joint Commission, 2005a). The main difference

between the Joint Commissions reporting system and the NYS Patient Occurrence Reporting and

Tracking System was a trust in the anonymity of the NYS reporting system by clinicians.



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When a patient is harmed by a medication error, that person or their family seeks to find the

person who has caused the pain (Nordenberg, 2000). Nurses make up the largest class of

employees in a hospital (Aspden et al., 2007) and so nurses have become targets of blame due to

their numbers and interactions with patients alone. The Joint Commission now advocates one of

the methods of achieving patient safety is ³to talk and listen to patients´, explain why an adverse

event occurred and then offer an apology to the patient (Joint Commission, 2005a). Considering

it can take on average up to five years for a plaintiff suing a hospital to receive any

compensation, the Joint Commission recommends all practitioners offer an apology along with

fair compensation when an error occurs (Joint Commission, 2005a). The Joint Commission

remarks that this may lower insurance costs overall. Passing laws, which protect nurses and

doctors from using an apology as an act of admission of error in court may allow more error

reporting (Joint Commission, 2005a).

A second example of an embraced reporting system is the Medimarx system. Medimarx a

highly used, robust medical error reporting system that was established by the United States

Pharmacopeia (Hicks, Sikirica, Nelson, Schein, & Cousins, 2008). Since 1998 hospital staff have

contributed more than 1.3 million errors involving medications to its system (Hicks et al., 2008).

Trust in the reporting system and those who oversee its data were critical to Medimarx being

utilized by practitioners (Joint Commission, 2005a). Nurses need to trust the system they used to

report errors with, in part because they are the medical professionals in a hospital most likely to

administer medications to the patient, in part because they are the most visible. Unfortunately,

for doctors or nurses who make a lethal mistake, they can be exiled from the medical community

(Nordenberg 2000). From the victims and families standpoint, finding the person who created the

harm and blaming them can begin the process of closure over time (Nordenberg 2000). At this



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point fixing the problem with punitive measures is not working. Many health care agencies are

required to report medical errors but their report volumes show not much reporting is occurring.

With only 4,000 fatality reports coming from about 50,000 facilities each year, it is highly

unlikely that such a small number of fatalities from medication errors is actually correct

(Nordenberg 2000). According to Amanda Kennedy, Benjamin Littenberg, and Jon Senders in

their report U sing Nur ses and Office Staff to Repor t Pr escr ibing E rr or s in Pr imar y Car e over 1.5

million preventable adverse drug events occur every year with those over the age of 65 having

the majority of medication errors some 530,000 errors per year (Kennedy et al., 2008). Based on

that number of errors many more fatalities should be expected statistically if complete reporting

was occurring nationwide. A total of 530,000 medication errors reported should have produced

more than 4,000 fatalities statistically. This shows that the most critical errors, those involving

patient death are not being reported in this writer¶s opinion due to fear.

Overworked nurses are a reason in medication error as well. A nurse who has an extended

shift or who has worked overtime produces a greater number of errors, an increase statistically

from 14% to 22% (Wilkins & Shields, 2008). Compounding extended nursing shifts, emergency

departments are now being used as primary care facilities which are not their intended purpose

(Brewster et al., 2001). Ultimately, the strain on nurses is only exacerbated by the increase in

emergency department visits (Brewster et al., 2001). From 1994 to 2004 hospital emergency

department visits increased by 18%, but during that time the number of hospital beds decreased

by a total of 12% (Burt &McCaig, 2006). The increase of ER visits and the shortage of ER beds

could be one of the issues affecting the amount of medication errors that occur annually (Burt

&McCaig, 2006).With the fear of reporting and the lack of reporting, researchers are working

with minimal information to provide solutions about why medication errors occur. The error rate



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has been estimated at 11% of all doses administered, not including time shifts in the

administering of medications to patients (Aspen, 2007). This unfortunately can be stated in such

a way that one patient is expected on average have received one mistake in their medications for

each day they are in the hospital (Aspden et al., 2007).

There is such an increase in medication error, but a lack of verified reports of errors that

nurses have been continually questioned about why they do not report (Hohenhaus, 2008). We

know this because some reporting systems are utilized more frequently. One example being the

one implemented in New York (Davis, 2003). The health care system like no other, including

and especially in a hospital setting is extremely complex and errors are going to happen, but at

some point training and punishment for medication errors will not work (Nordenberg, 2000).

According to a Hospital and Nursing Home week article, pg. 16 published on April 3, 2008

injuries due to drug related errors cost each hospital on average 5.6 million dollars and results in

over 770,000 total injuries and deaths each year in the United States (Anonymous, 2008). The

South Dakota Board of pharmacy director wrote in a 2003 letter to the FDA his concern of the

number of errors that were being reported in his state (Jones, 2003). The South Dakota Board of

Pharmacy director suggested that the bulk of errors came from the writer of the prescriptions

(Jones, 2003). In addition, he cites the actual writing of the prescription and the reading of them

as the number one issue of medication errors followed by sound alike prescription names.The

reporting of such great numbers of medication errors, when they are reported has alarmed the

FDA. In response the FDA has taken the action of creating a new position, the Office of Post

Marketing Drug Risk Assessment, which tasks is the analyses medication names (Nordenberg,

2000) as was previously mentioned before.



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The South Dakota Board of Pharmacy¶s executive secretary Dermis M. Jones, R.Ph. (2003)

is in agreement with such a move as he had suggested it in his letter to the FDA. In Dr. Jones

letter to the FDA, he stated that sound-alike medication names could be ³prevented from the

beginning when approving new drugs for market´ (p. 1). At this point if the FDA makes a

determination that a new drug¶s name is too similar to another drug already on the market as to

potentially cause future medication errors, with coordination and cooperation of the drug maker

they will work to alter the name of that drug. The potential re-wording of the name of the drug is

in hopes to prevent such consequences as look-alike, sound alike errors from occurring

(Nordenberg, 2000). Technology has improved patient care in hospitals greatly but preventing

sound alike drug names when writing a prescription is a low technology way to lower the rate of

incidence.

Nursing shortages (Facilities 2005; Burt and McCaig, 2006), bed shortages, sound alike

names, prescription illegibility (Kennedy et al., 2008), health care industry complexity and

punitive actions all combine to create an atmosphere of increased medication error and a desire

not to report those errors that occur. Nursing stress, inexperienced staff and having less staff on

shift than needed, compound the issues that affect patient safety and levels of medication errors.

Protocols that are no adhered to, the pressures of time and the lack of nurses in the job field in

general are other factors contributing to medication errors. Education levels of nurses seem to be

correlated with medication errors. Bailey, Engle, Luescher, and Taylor in their paper Medication

E rr or s in Relation to Education & Medication E rr or s in Relation to Year s of Nur sing

Exper ience, found that nurses who viewed their health care faculties safety systems as redundant

and capable tended to more frequently than more cautious nurses violate one or more of the five

medication rights (2005). These five rights are also documented in the Gale Encyclopedia of



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Nursing and Allied Health, 2nd edition (Krapp, 2007), under the article Administ r ation of

medicine. According to that article, it recommends keeping medication records on the person

during medication disbursements to the patient that can increase accuracy and patient safety

(Krapp, 2007).According to Bailey, Engle, Luescher et al. (2005), the five medication rights are

³right patient, right drug, right dose, right time and right route´ (pg. 2). However, it is possible

that with a shortage of nurses and over capacity emergency roomsthat a reliance on error

checking technology could be seen as a way to decrease the workload for a nurse by the nurse.

However, too much reliance on system tools at some point will fail the person who relies on

them to heavily.

This assumption might reflect on the fact that latent factors, those that occur behind the

actual visible medication error events occur throughout the medication use process. Nurses are

governed by the system and processes within their health care facility, in the context of this

report being hospitals. Nurses in hospitals are most often charged with the duty of dispensing

medications to patients and so operate in the constraints of the hospital medication system set up

within their hospital (Aspden et al., 2007). Nurses operate within the medication workflow

patterns that they are employed into, most often then the errors are at least shared in their

creation by the system in which they work (Aspden et al., 2007). One practitioner most often

does not cause medication errors but by many practitioners along the chain of prescribing events

(Aspden et al., 2007). Medication errors are not caused by one single malfunction in a hospital

but by many. According to Aspden, ³we must look beyond blaming individual behavior and

focus on the multiple underlying system failures that shape individual behavior and create the

conditions under which medication errors occur´ (p. 45). Nevertheless, according to Hohenhaus

in her research on medical error reporting 33% of those nurses that responded to her survey



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reported that they were afraid to report medical errors they had made (Hohenhaus, 2008). In the

same survey, 51% of the nurses responded to her questionnaire by themselves that if no harm

occurred to the patient as a result of a medical error done by the nurse responding to the survey

that they would not report it (Hohenhaus, 2008).

Without reporting these errors, it then becomes difficult to generate the quantity of data

needed to create statistically relevant and accurate models. These more realistic models could be

used to increase the efficiency and the accuracy of the medication dispensing systems in

hospitals. Without the accurate reporting of errors that actually occur, we cannot develop

accurate models that can show us how these errors can be reduced and thus save lives. With such

alarge number of medication errors as reviewed above and deaths related to those errors, some

type of ethical framework must be developed to provide a foundation for which those health care

practitioners and legal entities involved can find trust in each other. This ethical framework is

required because without trust errors with not be reported by practitioners.

Support for nurses is fundamental because a lack of such support can increase medication

error because abandonment by the system you work for increases the fear of reporting an error.

A legal and ethical framework that works will give this support to nurses, patients and our

regulatory agencies. The rational is a simple one, if there is little support for one¶s actions; you

are less likely to produce those actions. Support for nurses must start with the administration of a

hospital. Only 12% of nurses in a survey sent out by Hohenhaus MA, RN viewed their hospital

management as supportive to them (Hohenhaus, 2008) There is too much silence between

nurses, doctors and patients about medical error issues (Facilities, 2005). Those in the health

care community are hesitant to comply with the mandatory reporting of medical errors because

of liability and the potential for expensive litigation (Facilities, 2005). Silence on compliance



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The Lack of Clinician Support in the Reporting of Medication Errors

Few studies on medication errors and their frequency have been published, but those that

have show high levels of medication errors in health care facilities (Kennedy et al., 2008). These

error-reporting frequencies rely mostly on voluntary reporting. However, researchers would

prefer the volume of these reports to be higher than they are for statistical accuracy in their

studies (Kennedy et al., 2008). Those reports that have been published that record medication

errors frequently include other types of health care mistakes such as surgical errors or delays in

treatment (Joint Commission, 2008b). When researchers review such reports, the grouping of

different types of errors makes it difficult to determine how medication errors can occur because

they are not separated categorically in these studies. More narrowly targeted studies on select

kinds of medication errors can root out causes of error that we do not as of yet know of

(Kennedy et al., 2008), but only if enough reports are generated to study.

The lack of error reporting creates an information scarcity. This scarcity of information

causes the quality of research a researcher can produce to decline. A greater amount of data

about how errors occur and there frequency would create depth in new research on them, but

only if more errors are reported. Kathryn Wilkins and Margot Shields in a report entitled

Corr elates of Medication E rr or in Hospitals remarked that ³most«medication errors have been

based on data gathered from clinical records which are well known to yield incomplete data´ (pg.

9). The author¶s remark that only 5% of life threatening medication errors are found to be

recorded in a patients chart upon later review (Wilkins &Shields, 2008). The Joint Commission

Accreditation of Health care Organizations (JCAHO), now known as the Joint Commission and

the commission on Professional and Hospital Activities (CPHA) developed external quality



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assurance mechanisms in part to monitor hospital safety (Natarajan&Hoffmeister, 2005; Kohn et

al., 2000). This monitoring had the effect of driving heath care facilities toward safety

improvements through their outside enforcement of standards (Natarajan&Hoffmeister, 2005).

Positive benefits have occurred with this type of oversight such as a reduction in hospital-

acquired infections (Natarajan&Hoffmeister, 2005;Kohn et al., 2000).

The culture of hospitals is a psychologically real barrier to reporting. A caustic culture of

ridged organizational roles and competing factions can exist among departments promoting

indifference between clinicians (Meaney, 2004), this indifference shows itself as lack of support.

Aspen reported one case in particular to show an example of how reporters of medication errors

are penalized in the research article Pr eventing Medication E rr or s: Quality Chasm Ser ies. The

case profiled illustrates the variety of latent failures in the medication systems of hospitals. In

that case three nurses were charged in the negligent homicide of an infant when 1.8 ml of

Permapen was administered by a slow IV push. This amount of Permapen resulted in the

obstruction of the infant¶s blood flow to his lungs, the infant later suffocated. During the trial of

the two nurses, 50 latent and active failures were found to occur along the medication dispensing

process (Aspen, 2007). Some of the many failures included the pharmacist¶s filling the wrong

dosage of Permapen, the misdiagnoses of the infant¶s illness and the poor labeling of the syringe

(Aspen, 2007). Such negative responses in the health care industry toward nurses such as the

example above create a stifling effect on those who wish to report medication errors. In the

above-mentioned case, later analysis uncovered incomplete clinical information and the use of

non-standard means to communicate the drug order to the nurses (Aspen, 2007).

With repercussions for nurses who are found making errors being suspension up to

possible criminal charges, there needs to be a more positive and supporting hospital



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administration. The lack of positive clinical support for those who report medical errors is not

just isolated to the US. In the United Kingdom, a House of Commons health committee was

assembled in 2008 to review error-reporting claims that many health care facilities are ignoring

official processes that are there to protect nurses when they reportself-made errors(Snow

&Doult, 2008). At the committee, testimony was heard from experts that incidents of medication

errors were under-reported due to the pervasive culture of blame within many English health care

organizations (Snow &Doult, 2008). The committee thus decided to take up a review of different

ways incentives could be used to improve the quantity of medical error reports submitted to

officials each year (Snow &Doult, 2008). One professor at the committee providing written

evidence on the culture of blame, Matt Griffith commented that, ³if clinicians«concerns are not

acted on, they may become disenfranchised and less likely to report [errors] in the future´ (pg.

7).

If medication errors are caught at the time when the errors meet the patient this errors are

then referred to as a sharp-end errors(Joint Commission, 2005a). Sharp end errors are often the

most apparent and visible in a hospital (Joint Commission, 2005a). In contrast, blunt-end errors

occur in the many layers of a health care organization that are not seen by the patient, but

influence the actions of the clinician servicing the patient (Kohn et al., 2000; ³Latent Error´,

2007). Blunt-end errors often go un-noticed until an actual sharp-end error hurts a patient (Pratt,

Thoimas& Atkins, 2005; Facchinetti, Campbell & Deirdre, 1999). These blunt-end or latent

errors (³Blunt End´, 2007), as they are also called although not clear, influence how a nurse

functions in a health care facility. Latent failures while they are not as clear never the less

contribute to the apparent occurrence, the ones we usually see (³Active Error´, 2007), the sharp-

end medication errors that can injure patients (³Active Error´, 2007). An example of latent



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failures in a system giving rise to active errors and how data from the field was able to cut active

failures and was in the field of anesthesiology. During the 1980¶s, a total of over six-thousand

people undergoing surgery were injured or died during the procedure as a result of the anesthesia

given (Joint Commission, 2005a). Engineers then began examining how these adverse events

were happening, what types of anesthesiology equipment was being used during the procedures

and how the equipment was used during those procedures. Engineers, with the information

learned by examining the context of anesthesia errors produced during surgery many of the

process involved in that field were redesigned (Joint Commission, 2005a). After redesigning

many of the systems involved in administering anesthesia, death rates fell to one in 200,000

persons (Joint Commission, 2005a).

Judgments against nurses or doctors in favor of medical liability on the reporting

clinician do not always show that the error involved was negligence on the part of the clinician;

it could have been the system itself (Joint Commission, 2005a). If the actions of nurse are

affected by the systems they work in, then liability should be applied to the systems that order

the actions of the nurse. In an New Mexico Business Journal Article entitled T he P endulum

Swings- A Histor ical P er spective, the author (2001) sums up the current culture in hospitals as

³Error [equals] somebody¶s fault: assign blame«move on. When an error occurs it is a natural

impulse to assume that someone is at fault without establishing the facts«Don¶t do it again, or

else«´ We need to shift the culture of blame that is in hospitals to a just culture (³The Pendulum

Swings´, 2001). A just culture includes the intentions of the clinician and his or her attitudes. A

just culture is structural as well as it has to do with attitude (³The Pendulum Swings´, 2001).

Finally, a just culture is fair and proceeds through the logical steps of ethics (³The Pendulum

Swings´, 2001). Trust in a system is shaped by a person¶s perception and experience with that



Page | 31

system. Perceptions and experiences about that system can be changed if what they experience

with that system changes, this can be done through new experiences based on strong ethical

rules.

Nurses, according to the Staffing and Resources Adequacy Subscale, survey typically

lament that there is too few nurses on staff. Because there is too much work but not enough staff

nurses remarked on the survey that they could not get all their work done before the end of the

day (Wilkins & Shields, 2008). Two-thirds of those nurses surveyed felt they had too much work

to do while 62% felt they had so much work to do that they could not do all of it and keep up

their own personal standards of quality (Wilkins & Shields, 2008). A total of 65% of those

nurses surveyed voiced the concern that they had to work through their scheduled breaks too

often and 55% said they had to extend their workday often just to finish their days work (Wilkins

& Shields, 2008). The strain on nurses is typically extended into the rushed filling out of patient

charts. These charts can become a flaw in the chain of data management when through stress

clinical reports are rushed (Wilkins & Shields, 2008).

Paper charts can vary in form often written in short hand and using quick shorthand

abbreviations that turns them into ³cook-books (Woolf, Kuzel, Dovey, &Kuzel, n.d.). Hospital

Administrators, doctors, nurses and researcher all agree that paper charts must have some

consistency from chart to chart within a hospital. According to Steven Woolf, Anton Kuszel,

Dovey and Phillips treatment errors begin ³with errors in communications´ and ³suggest that

safety initiatives should focus less on professional interventions to improve clinical judgment

and more on management systems´ (Woolf et al., n.d.).The authors suggest this because poor

communications between clinicians often because of poor workflow. Focusing on making

improvements on management systems would enhance the reliability of information that moves



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through the hands of many professionals on a hospital ward (Woolf et al., n.d.). To lower the

number of medication errors in a hospital, the sequence of pharmaceutical events, from

prescription writing, to pharmacists reading the prescriptions, to the pulling of the medications,

to drug distribution must be studied. Everything from nurse¶s personal values, to how

professional the nurse is at his or her job must be considered in any attempt to re-structure

medication distribution (Facchinettiet al., 1999).

In traditional markets, buyers exert pressure on the quality of products because of their

ability to purchase or not to buy a manufactures product, depending on how they view the quality

of the product at a certain price. The quality of a consumer product for purchase is apparent

through review, comparison and competition. However, with the health care industry the ability

of its consumer base to decide product quality is masked by such entities as third party payers

(Natarajan&Hoffmeister, 2005). These third parties set both the quantities of a health care

service that a consumer can buy and the price at which that person can buy it

(Natarajan&Hoffmeister, 2005). The purchaser does not have access to the information on a

health care products true cost and information on the amount of that product a person can use is

limited to what he or she¶s insurance will pay (Natarajan&Hoffmeister, 2005). Product design

knowledge is limited to those who carry out its procedures be it doctors or pharmacist and does

not trickle down to the consumer (Natarajan&Hoffmeister, 2005).

In other industries buyers and consumers have a large total voice in the outcome of the

final product a manufacture produces (Natarajan&Hoffmeister, 2005). The quality of medication

delivery through a hospital cannot be improved beyond what it is now if greater numbers of

reports are not gathered for analysis. At best, withthe numbers we now have access to regarding

medication error frequency and type, our picture is statistically incomplete (Aspdenet al. 2007;



Page | 34



Page | 35

Modeling and Modification to Prescription Workflows

The process of information modeling in health care settings is unique and difficult to

analyze because in many health care facilities authority is shared between the medical staff and

the administration of that facility (Natarajan&Hoffmeister, 2005). These dual chains of

command cause potential positive changes in hospital policy to progress slower than would be if

only one command structure was involved. Within industries such as manufacturing, only the

administrative staff has sole control of system design, implementation and oversight. Another

impediment to health care system modeling and reform is that hospitals and health care

professionals attempt to decrease the potential for litigation (Natarajan&Hoffmeister, 2005). This

attempt to decrease the costs involved with litigation creates an incentive to suppress information

with anyone outside of the organization, including medication errors. Thus, with a drought of

reliable data, analysis of error reporting becomes difficult because you cannot analyses what is

not there. According to T he Gale Encyclopedia of Nur sing and Allied Health, a prescription error

is defined as having one or more of the following attributes ³[being] the wrong drug, [the] wrong

dose, at the wrong time, or [a dose given] via the wrong route. Omissions of medication [that

should have been given] are also considered errors´ (Hauswirth&Longe, 2007). This increase in

the risk of injury does not necessarily include the act of harm, only the potential increase in the

risk of harm when taken in context with the standard treatment for that ailment the patient has

(Kennedy et al., 2008). With confusion on authority, definitions of error, the fear of litigation and

reporting errors it is to be expected that the truth would be that much more difficult to find.



Page | 37

and is difficult to utilize beyond just the surface details about a patients current conditions

(Hagen& Johnson, 2008).

One of the most significant issues that must be resolved before a thorough quality

management approach can be effective at bringing down the rate of medication errors in

hospitals is for professionals in the health care industry to decide what makes up a medication

error.

Nat Natarajan proposes another definition of an error in the journal article and Amanda

Hoffemister, Do No Har m: Can Health car e Live U p to It? In that article, an error is defined as,

³the failure of planned action to be completed as intended or the use of a wrong plan to achieve

an aim´ (Natarajan&Hoffmeister, 2005). This definition expands on the earlier definition to

include blunt errors as well as sharp errors. What makes up errors and what kinds of errors make

up certain classes or categories need to be universally agreed upon. The NCC MERP Index for

Categorizing Medication Errors is the closest universal classification systems for errors that we

have based on current research regarding medication issues in health care settings (³NCC MERP

Index for Categorizing Medication Errors´, 2001).



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Figure 1



Page | 39

Information about a patient¶s diagnosis is passed from doctors to nurses and to

pharmacists. It is through these information transfers where essential data can be lost, the

necessary written and verbal information that must be accomplished to help the patient recover

can be compromised (Medication Gaps AHIC Extension/Gap, 2008). If essential information in a

patients paper chart is missing because of inconsistent handoffs between clinicians, there is no

way a nurse will know except through a review of the chart. A paper chart cannot tell the nurse

of missing forms, the incompleteness of filled in forms, or drug incompatibilities of drugs

prescribed to the patient unless the nurse can spot these information gaps. The transfer of

information by applying uniform standards can improve the ability of doctors and nurses to

exchange information (Medication Gaps AHIC Extension/Gap, 2008). Standards that can expand

the breath and accuracy of communications in hospitals must further pursued. Some standards

that can be improved are the accuracy of a patient¶s allergy information and the tracking of side

effects from medications that are given to patient (Medication Gaps AHIC Extension/Gap,

2008). Without improvement in staff communications, accuracy breakdowns if severe enough

will result in medication errors (Joint Commission, 2005a).

The accuracy, timing, and the treatment of a patient combine to dictate the patients care

(Natarajan&Hoffmeister, 2005). Within any one of these patient care components, an error can

happen that can result in a patient harm. Providing the wrong treatment, the right treatment at the

wrong time to the patient can injure the patient (Natarajan&Hoffmeister, 2005). Poor health care

practices such as fragmented patient treatment coordination can hinder a hospital in the battle to

reduce medication errors because of thehealth information each patient¶s accumulates during the

process of his or her treatment (Natarajan&Hoffmeister, 2005). Patient treatment requires

information about the patient¶s condition and the context to treat the patient. However,



Page | 40

information and its context can shift during care leading to medical errors. If a hospital cannot

coordinate the many information streams surrounding its medical staff about a patient treatment

that hospital can impede its own quality management practices. In such cases, total quality

control procedures from manufacturing or industrial companies can be transferred from them

into the health care industry (Natarajan&Hoffmeister, 2005).

Standardized electronic health care databases, and the types of patient information sets

stored in them are still at the development stage, but many providers are implementing them or

making plans to carry them out now (Keston, 2009). Facilities have been moving toward

electronic healthcare records or EHR adoption for some time. Providers that are furthest along in

implementing their EHR systems cite the need to share patient information with those who

require those records such as their doctors and nurses (Fonkych& Taylor, 2005). Those hospitals

that indicated a reluctance to add new EHR systems cited a lack of support from key

stakeholders, most often those being medical staff and the perceived lack of ROI or return on

investment. However, a majority of hospital that were implementing EHR or HIT (Health

Information Technology) systems did not cite ROI as enough of a limiting factor enough in

which to their stop investment in these systems (Foknkych& Taylor, 2005). Fonkych and Taylor

also cite the need to improve clinical processes as previously mentioned; how the various

streams of workflow information move through hospitals (2005).

Other types of system definitions that must be taken into account can include operating

rooms and obstetrical units (Kohn et al., 2000). One system can be linked to another or more,

becoming a network of systems in a larger health care network (Kohn et al., 2000). The way in

which information and workflow through these systems can be developed or can be altered is

through the re-modeling of them. Modeling then is essential to the understanding of complex



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systems that are necessary for a health care facility to work efficiently and accurately. Effective

modeling is also required to change these systems. Good modeling achieves this while

minimizing logical errors, otherwise known as syntax errors, in the new model to be installed in

a facility. If a newly developed EHR/HIT system id installed in a health care facility with syntax

errors, then the new system could later on develop errors eventually harming patients (Rittgen,

2009). Enterprise modeling of HIT or EHR systems as ERH modeling is also called consists of

domain experts who have the raw knowledge to create the model and stakeholders who would

have to use the model if it is installed in the facility (Ruttgen, 2009). These stakeholders are

again the staff of a hospital such as doctors, nurses and technicians.

Banner Health, a hospital system in Arizona was so convinced that the EHR/HIT systems

that they originally had in place, was not working for them that when they built their new

hospital they re-standardize all their policies in order to facilitate their integration with a newer

HIT system (Hensing, et al., 2008). Banner Health Care with advice from doctors, nurses,

administration, IT and other staff was able to alter 92 of its internal processes in a dozen core

areas. Banner Health Care was able to change processes across departmental lines and the

interactions that occur between multiple departments (Hensing, et al. 2008). With EHR¶s, HIT¶s

and other systems stakeholder buy in is critical, these stakeholders are doctors, nurses,

pharmacists, specialists, technicians and administrators. Stakeholders must see the worth of

integrating a new system into their facility and then must utilize it (Fonkych& Taylor, 2005). It is

trust in the modeler, trust in the ability of the system to perform as it should when installed

which will decide if the finished product is error prone. If these stakeholders do not see the worth

of such systems, installation and utilization of the new EHR/HIT system would be very slow if at



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all (Fonkych& Taylor, 2005). With any system that must be modeled real input and buy in is

required to get any usable and functional network designed and in place.

Various methods of analysis determine how we study an issue. If a researcher

undertaking information modeling researches a data retention issue with his focus on entity-

relationships, he will focus on entities but not on processes (Siau, 2002). If that same researcher,

views the same data retention issue, but emphasizes objects, he will focus on how the objects in

the data system behave (Siau, 2002). Furthermore, a sample of the many schematic frameworks a

system designer or researcher uses can influence the study of an issue. A few examples of

information models that can be used to understand EHR/HIT systems are ³data flow diagrams,

entity-relationship diagrams, use cases, activity diagrams, sequence diagrams´ and others such as

flow chart visuals which display how work moves along a given path (Siau, 2002). Developing a

workflow schematic to follow for which a computer model will then be later designed, or to lend

enough detail for a Health care administrator to re-design a work process can be difficult in of

itself. Unfortunately, this is because our Health care System is one of the most complex work

environments that we know of (Lewis & John, 2003). In the case of Banner Health, the hospitals

administration knew that the old methods of workflow were not consistent among departments

and so during the building of the new facility they began the revamping of their system

(Hensing, et al., 2008).

Differing methods of modeling allow a researcher to study the same pharmacy processes

in unique ways. An activity diagram is an overview of a particular process that an analyst wishes

to study, while a sequence diagram is oriented by the amount of the time each work function

takes to be completed and sent on to another person (Lewis & John, 2003). For the researcher

each method gives the analyst another view into the issue that is being studied for a possible



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solution. Research into the systems, which allow researchers to analyze a set of process, such as

how medication moves through a hospital, is still somewhat an art. However, even after decades

of development these modeling development programs, if developed on sound theoretical

footings can yield insight into what we see as our reality (Siau, 2002).

Group modeling is accomplished through UML activity diagrams with the end goal being

fully complete, correct models without any missing actions and without any unrealistic actions

(Rittigen, 2009). The term correctness means that the model reflects reality; stakeholder input is

often required for this correctness (Rittigen, 2009). The term completeness means that the system

is not missing any logical statements that are required for the model to work appropriately in the

setting for which it was designed (Rittigen, 2009). These types of collaborative activities, again

require trust by the constituents involved that the model will be worth their time and their effort.

Modeling is collaborative process; personnel costs are high with such exercises because most

often experts from the health care facility, health care administrators, and doctor/nurse

administrators are required to take part (Rittigen, 2009). Personnel costs are high because in

modeling the constituent previously mentioned continue to receive their salary while modeling,

but are not at their jobs until the modeling is completed (Rittigen, 2009). If the administration of

the hospital do not see the exercise as fruitful then the number of those involved in the modeling

exercises can be reduced, however as Rittigen (2009) notes ³the number of involved people

cannot be reduced without sacrificing model quality´ (pg. 229).

The modeling of prescription workflows requires the use of tools and a need to develop

testable and repeatable error free logical arrays, or decision points (Hassell& Holmes, 2003).

These decision points should be error free meaning that they do not return errors when coded

later into the software applications that will be installed in the hospital (Hassell& Holmes, 2003).



Page | 44

Two of the many tools used in system design are linguistic analysis and UML (Hassell&

Holmes, 2003). One specific UML modeling tool is Rational Rose (Torchiano& Bruno, 2003).

The locating of where a breakdown in a system has occurred requires a process in itself. First,

the existing business model that the stakeholders wish to change is analyzed (Torchiano& Bruno,

2003); in this case study, this would be the handwriting of prescriptions. Once the previous

system is outlined, the new system is built from predefined types of logical building blocks that

the modeling software program has already built into it (Torchiano& Bruno, 2003). What is to be

kept or left from the old EHR/HIT systems is a decision for both the modeler and the

stakeholder¶s, each decision point being a building block to be kept or discarded. That which is

kept from the old system is included in the new EHR/HIT system through the adding of building

blocks to fresh model. These predefined building blocks could be human activities; system or

computer processes or logical choices that nurses make during their shift on the hospital ward

(Torchiano& Bruno, 2003). Because the modeling of health care systems involves many systems

and many constituents it is often called enterprise modeling. Enterprise modeling most often

involves a facilitator, the system modeler previously mentioned, who in a chauffeured way

drives the modeling process forward (Rittgen, 2009). The chauffeur again typically uses

modeling tools, such as computers, modeling software and whiteboards (Rittigen, 2009).

Quality control charts can be made for process one example being the checking of

medicine as it travels through a hospital at various times before the final dispensing of

medications to the patient (Facchinetti et al., 1999). Many of these modeling programs are now

sophisticated enough to generate production quality code from the building blocks themselves,

which domain experts can use to generate the software which will be installed at the hospital

once they are finished with modeling (Kobryn, 2000). UML components when combined



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resemble model diagrams or component diagrams (Kobryn, 2000). Modeling is done to lower the

risk of system failure, business failure and for businesses to function in the way they are required

to once the new network systems are installed (Hassell& Holmes, 2003). In modelingfor

example there are agents who can be the health care employees in a facility andartifacts, which

can for example can be the medical records they deal with (Hassell& Holms, 2003). In

information modeling employee¶s orders, those they give or write can be represented by

tasks(Hassell& Holmes, 2003).

Withoutaccurate reporting of active or also defined as sharp-end errors there will be less

accurate statistical research on those errors, this will produce a less accurate body of literature for

domain experts to become experts in. In this author¶s opinion, this will cause less accurate

models to be developed when rolled out. These information systems will then be less accurate

when used in a health care facility; latent errors left in or created during modeling will become

flaws in the new system. The process of information system creation is formed by modeling that

is created from a variety of pre-made class and connection blocks (Tochiano& Bruno, 2003).

Decisions make up these pre-made classes and their connecting blocks (Tochiano& Bruno,

2003). However, if we do not know that certain active errors are caused at example Y decision

points because Y errors are not reported, leaving X decision point errors more prominent in the

overall analysis, then domain experts and stakeholders will focus on eliminating X decision

points. Thus, those X decision points will be the focused on when the new information system is

modeled. In essence, unfound errors in the old EHR/HIT system may inadvertently be grafted

right into the new EHR/HIT system. This leaves Y decision points ignored and may lead to latent

errors in the new system. Y decision points could be overlooked because few people are

reporting them leaving research on those error points veiled, in this thesis this would be points



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where medication errors occur. Few nurses or doctors relative to the quantity of estimated

medication errors in the US per year are reported because of the fear of losing one¶s

carrier(Aspen, 2007; Hohenhaus, 2007). Meany has summarized this fear in his journal article

titled, E rr or r eduction, patient safety and institutional ethics committees:

Authors on the subject of (error reporting) have almost uniformly concluded that

the health care industry has failed to design systems for patient safety, relying instead on

requiring individual error-free performance enforced by punishment. As HCR notes,

there appears to be an entrenched belief in the industry in the effectiveness of blame and

punishment for error prevention, a conviction reinforced by highly punitive legal and

regulatory systems and the public media. In short, the industry has relied almost

exclusively on threat of legal, financial, or disciplinary penalties to insure patient safety,

and operates on the assumption that most patient injuries result from bad behavior (e.g.

incompetence, negligence, or corporate greed) in short; a culture of blame pervades

health care.

One example of a system design that has been validated, or otherwise known to be

accurate in improving safety culture is the CUSP 6-step method (Pronovost, Berenholtz,

Goeschel, Thom, Watson, Holzueller, et al., 2008). Each step in the CUSP process requires

either an assessment such as; staff straining, staff education, system or logical defect

identification, or resource identification (Pronovost, et al., 2008). The SAQ or assessment

portion of the CUSP 6-step method requires hospital staff to communicate their responses to

questions about teamwork, their attitudes about management, working conditions and how they

deal with stress (Pronovost,et al., 2008). The CUSP 6-step model also requires that management,



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clinicians and work teams come together to rank and offer solutions to prior safety hazards

(Pronovost, et al., 2008).

Once the EHR/HIT model is developed, the systems can be implemented within a

hospital. Once the EHR/HIT is installed, new processes can be implemented in retrieving

artifactsfrom the hospital. Barcode-POS systems can be used with which to scan both medication

packaging and the patients wristband to verify if the barcodes match (Hassell& Holmes, 2003), if

the wristband barcode matches the medication barcode then that medication is for that patient.

This may seem simplistic, but many errors as previously mentioned involve wrong patient,

wrong drug errors. These types of EHR/HIT tools would tend to decrease human error.

Pharmacy information systems can be implemented to digitize doctor¶s handwritten prescriptions

to then be sent to the pharmacist for review and filling (Hassell& Holmes, 2003). The digitizing

of written prescriptions can reduce reading errors. If for example, a patient were not prescribed a

certain medication the nurse dispensing the medication to the patient would be alerted before

giving him or her that pill, tablet, injection or IV (Hassell& Holmes, 2003). Mobile medication

cabinets can dispense high alert medication at the patient¶s bedside with proper authorization

required and with records of the transaction that occurred stored in the cabinet¶s memory for

future review (Hassell& Holmes, 2003). PAC¶s should be able to digitally store X-rays and other

data such as MRI¶s and CAT scans which can be appended to a patients file for viewing by the

doctor on the ward floor (Keston, 2009). Finally, pharmacy systems should provide pharmacists

with the patient¶s medication history and his or her current list of dosages with thisinformation

able to be digitally transmitted to the doctor or nurse for review (Keston, 2009).

Why should modeling be done in the context of prescription management; because

modeling is one of the few ways practitioners, engineers and IT technicians can share their past



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experiences about what works or does not in a hospital. It is through this collective exchange of

information that professionals then bring what they learned together to weed out persistent latent

problems that could only be found by a group effort. Groups like these once assembled can over

a period of weeks discuses what actions produce errors and what do not, developing a new

system together. Hindsight brought into a new system can take the best of what was, add new

functionality and weed out stubborn error processes that were found over time by utilizing the

older systems within the hospital they work in.



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Automated hospital Medication Processes

The reform of hospital processes if implemented thoroughly will reduce overall

medication error levels in hospitals. Hospitals can carry out this reform though an increase in

accuracy of its procedures and the efficiency of its procedures. Hospitals must attend to

inefficiencies brought on by their paper prescriptions, charts and paper billing rules. The most

efficient means to do this is the installation of EHR/HIT software systems in hospitals replacing

traditional paper records. These new electronic information records must go beyond patient

insurance and identification, to include the patient¶s complete chart (Keston, 2009). This

complete chart would include his or her complete medical history within that hospital, not in

paper form on the ward floor but in digital form. This digital form should allow for the easy

updating a of the patients chart (Keston, 2009). EHR¶s can also allow a patient¶s medical history

to be shared at the same time within the same hospital (Keston, 2009). Some EHR systems also

expand on sharing to allow a patients record to be accessed by many other organizations outside

of the main facility (Keston, 2009).

Many health care facilities do not have EHR¶s in place or if the given facility has an EHR

in existence it is a closed unit electronic medical record, just within that clinic or hospital

(Keston, 2009). With closed unit electronic medical recorded systems patients are often required

to repeat all their vital statistics each time they see a new doctor or another health care facility

(Keston, 2009). Unfortunately, with contained EHR systems the responsibility for the accuracy

of a person¶s vitals shifts to himself completely and the patient¶s mental record. If the patient is

inaccurate on his or her past vitals, that information can become part of his permanent record at

any new facility (Keston, 2009). He or she sees some examples of this when a patent must report

over again his or her high/weight, prescriptions, prior surgeries and family histories. According



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to Geoff Keston in his report, Developing the Standar d Elect r onic Health Recor d , a complete

EHR systems can prevent such record errors because one update of the patient record would

change all records where the EHR is needed (Keston, 2009). A patient who has reported an

inaccurate height or weight for himself can be at risk for medication errors simply because the

dosage of a medication is adjusted to match body mass, if the mass is wrong the dosage will be

in error as well.

EHR¶s are currently limited in geographic scope, or are employer based at this time

(Keston, 2009). Many EHR/HIT systems are also limited to a specific population of individuals,

such as the US Dept of Defense health care system which was established for just its employees

or EHR systems set up by companies as Dell, IBM or CISCO for just their own employees usage

(Keston, 2009). The most universal or wide reaching EHR system at this time is being developed

by the NHIN which could be expanding nationwide in scope sometime in the near future

(Keston, 2009). However, smaller employer based systems are further along in qualitative

development than the NHIN model, but again do not cover as many people. Only the US

Department of Defense¶s EHR/HIT system serves a large enough employee and retiree client

base, now over nine million persons (Keston, 2009) to be considered national in scope. As EHR

systems continue to develop and improve, specific recommendations that are now set in place on

how they should perform and operate will offer the most benefit later whether rolled out if only

certain hospitals or perhaps nationwide.

Once in place, EHR¶s can cut costs by eliminating redundant administrative tasks

(Keston, 2009). Properly implemented EHR¶s/HIT¶s can cut the fragmented delivery of health

care that is in place today in many hospitals (Stefanelli, 2002). This redundancy and the

fragmentation of health care processes results in the poor treatment of patients, with many hands



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doing incomplete jobs or many of the same tasks in health care facilities resulting in higher

medication error rates at that facility (Stefanelli, 2002). If the new EHR¶s are embraced and fully

utilized by the staff of a hospital the results are astounding in regards to hospital efficiency and

patient care.

True long lasting error reduction will only come from an approach integrating an ethics

based secure reporting system, a new social health care contract and efficient systems, with

efficient systems easing the burden on nurses. Much of the difficulties of automation in a

hospital setting come from the complexity of the jobs within the hospital and in the duplication

of what our bodies can do such as with our vision and our speech (Armoni&Khosrowpour,

2002). The detection of errors before they happen requires the ability of nurses to find the errors

before the medications are administered to the patient. To a nurses experience automation adds a

second layer of error detection and can be an excellent support tool for nurses beyond just their

own eyes (Pratt et al., 2005). However automated systems are only tools to be used with

improved patient safety, labor productivity and with staff participation in quality control

(Hensing et al., 2008). Staff participation should include abundant error reporting that reflex the

real mix of medication errors that are occurring at the hospital level, but so far reporting has been

skewed and lacking.



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Policy, ethics and how they can affect the severity of errors, the lack of support, the modeling of

prescription workflows and the understanding of automated medication processes

Having automated technologies, reporting tools and modeling software can all bring

about a reduction in medication error, but having a functional framework for these tools to work

properly together in a hospital are a requirement for reducing medication errors. Without this

framework these tools will have little positive effect because they will not be grounded

cohesively, this is where policy and ethics form the rules needed to build the framework.

According to the Encyclopedia of Small Business, Automation is defined as ³the art of making

processes or machines self-acting [and] self moving´ (Hillstrom, 2002). Automation can bring

down the level of human errors because less human interaction is involved with the process that

once required more intervention that is human. Unlike human processes interaction, once set in

motion an automated systems is set in motion to perform the same task, it will do sorepeatedly,

with little variance ("Automation," 2007). Most hospitals are only now implementing automation

and robotic technology (Facchinetti et al., 1999). These automated processes are essential with

medication distribution in hospitals because of the high volume of prescriptions that are filled

each day in a hospital. If EHR¶s integrate automated data receptacles, then there will be less of a

chance for medication errors to occur in part because of the ability for a clinician to check the

accuracy information at multiple steps along its path through the health care facility. Where to

place accuracy checkpoints in the development of new EHR models depends on the quantity of

medication errors previously recorded, the types of medications involved in those errors and

when those medication errors occur. Where to place accuracy checkpoints when developing new

types of EHR/HIT software systems depends on the reliable reporting of medication errors.



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by people in positions able to create policy (Cochran & Malone, 2007). Stresses upon hospitals,

clinicians and patients have created an urgency to remedy the issue of medication errors in our

health care settings (Clarke, 2003). This urgency to fix broken systems in healthcare facilities has

cause well-meaning policy analysis and lawmakers to fill in the ethical cracks with piecemeal

approaches where sound action should have been taken (Clarke, 2003; Rajiskarian, Fairbanks &

Shah, 2008; Snow &Doult, 2008). Ambiguities cannot substitute for truth.

In this paper, the resource of privacy has to be weighed with the public good and only

strong identity management and the ethical policies behind it can treat those who need on both

sides fairly. Experiences shape how you view and issue. Medication error reporting has failed

because a nurse or doctor can lose their medical carrier for just one self-reported error, but is

required from them to change their hospital systems. In addition, nurse feedback is required to

modify their EHR/HIT systems for fewer errors (Joint Commission, 2005a). Management has

failed to develop or integrate safety policies into their hospitals or other health care systems in

large part because of the lack of reporting (Meany, 2004).

This literature review is an attempt to focus just on the need for error reporting polices

that work with clinicians, management and regulatory bodies. If better error reporting policies

are developed, then more errors will be reported and reports that are more accurate will be

created, allowing the development of better EHR/HIT systems. These newer EHR/HIT systems

will be less prone to malfunction and more efficient. With better EHR/HIT systems the

frequency of latent errors will decline and active medication errors simply because nurses would

be able to concentrate on potential human errors and not system created errors. Specifically I

propose a policy that integrates ethics into when to report a personal medication error and when a

reporter¶s identity should be revealed. I also propose an information system to carry out this



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policy. Again, according to Meany a culture of patient safety has to include psychological

factors, behaviors and systems geared toward that safety (Meany, 2004). In this researchers

opinion, one of these physiological factors is trust, trust that reporting will be beneficial for the

patient, the hospital system and the reporter more so than the potential punishment.

A better reflection of the quantity and types of medication errors occurring in hospitals

will alter EHR¶s over time driving the designs of EHR/HIT systems toward greater quality and

accuracy. Once these more efficient and accurate automated systems are installed in hospitals

those new systems will cause less latent errors to surface through their product life spans. This

paper so far has been a review of the body of literature on the quantity of errors, the systems

hospitals use in medication distribution, how those systems are created and in what direction

policy needs to shift in order to affect those systems positively. This positive shift would reduce

the burden of errors on nurses. For nurses and doctors fewer latent errors means less errors they

have to catch before they become active and less mistakes they have to report because they will

make less of them. In the end you cannot have a shift in how EHR¶s are created so that they

work better in health care facilities without better modeling, you cannot have better modeling

without better data, you cannot have better data without more error reporting and you cannot

have more error reporting without better policy.

A new ³just culture´ consensus has emerged as a new type of policy on error reporting.

Adding a just culture component to new error reporting policies is part of the incremental policy

shift we need in the health care field today. We need a policy of error reporting that provides

fairness, recognizing our human limitations, but can also be ethically strong enough to provide

critical assessments of a clinicians competence when required (³The Pendulums Swings´, 2001).

This new type of ethical policy can be called a just culture mentality or theory. This just culture



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starts with ethics and ethical constructs, which then can be the building blocks to newer medical

error policies and a new social contract between reporters and the systems in which they work.



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Ethical Constructs

Why should a nurse, doctor, or anyone disclose a mistake to another person or

organization? Why should a person reveal information about themselves to others through

communications? With a person¶s held beliefs and values, perhaps to some it seems ethical for

them to disclose a mistake despite the inherent risks of doing so. We live in societies that shape

those held beliefs each one of us has and although everyone¶s beliefs are different in nature we

share many similarities to others in values systems due to our shared cultures. Of course, the

spectrum of values within each culture is varied; majorities in belief do occur and even between

disparate societies themselves. In our history the ethical theories, which came to dominant

American culture through its history are, Utilitarianism, Deontology, Rawlins Social Justice,

Divine law and Natural law theories (Bluhm et al., 2007;Rachels, 1990). These ethical value

clusters were grafted into our culture through English common law, puritan theology, lockean

individualism, populism, associationism, and by the French enlightenment. Other ethical theories

such as Hobbes social contract, and recently Feminism have been added to our American value

system. Our collective American values are what we see in our culture today (Cochran &

Malone, 2005, Rachels, 1990). After studying these value systems outlined above and reviewing

commentary on the organizational make-up of health care facilities, in this researcher¶s opinion it

appears that Hobbes social contract makes up a large part of our Americans value system. In this

researchers opinion I also believe Hobbies theory makes up a large part of the social interactions

within a hospital. I believe Hobbes social contract makes up a large part of our American value

system in part because lockean theory was quite common during the American colonial era and

written in our constitution, embodied into it (Bluhmet al., 2007). It is visible in the rights and



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laws we have today in America. Throughout our history, natural rights and institutional agendas

as well as community social bonds have required the strength of contract law to balance our

personal wants with our community needs (Bluhmet al., 2007; Cochran & Malone, 2005). It is

these contract laws that are prevalent in America today that balance our personal wants with our

community needs.

However, an overview of major Western European ethical theories is required to see the

context of our American values. This overview of western European ethical theories is necessary

because it is these Western European beliefs that form our current value systems and the values

of the clinicians that work in our health care facilities. These European and American values are

what nurses use to decide whether to report an error. However, there are other logical reasons

why a nurse, doctor or technician would or would not report a personal error to another person or

constituency. According to James Rachels, ³Morality is, at the very least, the effect to guide ones

conduct by reason- that is the best reasons for doing.´ (pg. ). One reason a nurse would report an

error for example could be the fact that the act of reporting the error would benefit the patient or

society more than him or herself and that this benefit outweigh any perceived consequences

coming from this act. This assumption can be stated in a utilitarian way, such that the nurse

would rather promote the good of others rather than his own good (Rachels, 1997). A definition

of utilitarianism is the theory of personal values that decisions should be made such that the

outcome should satisfy the most people, or give the most benefit, prompt the least pain and

provide the most happiness to the most people possible (Bluhm et al., 2007; Rachels, 1997).

Utilizing a utilitarianism ethical approachwould suggest a nurse act to self-report her

medication error if she was somehow involved in the act. If the utilitarian approach suggests the



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majority over self in decision-making, then why are the estimates of medication errors in

hospitals higher than the actual number of those reported each year? Self-disclosure of any type

of personal information is deliberate; self-disclosure of an error is a conscious personal decision.

There can be risks and therecan be benefits of disclosing a personal error such that careful

deliberation would be necessary before someone self disclosed their own error (Adler, Russel&

Proctor, 2006). Utilitarianism is only one of many ethical theories that can be used to develop

ethics based policies on error reporting. There are value systems that can encourage as well as

discourage someone from reporting an error that he or she was involved with. Each of these

ethical theories attempt to explain how personal decisions are made.

A second relevant ethical theory that can effect self-reporting is Deontological ethics.

Deontological ethics or Kantian ethics separates what is a good action or a bad action from the

results of those actions; no matter which results they may be(Bluhm et al., 2007). According to

Immanuel Kant one founder and proponent of deontology, certain acts in of themselves are right

and wrong, that a wrong act committed even if it produced a positive result was still morally

wrong (Bluhm et al., 2007). Deontological ethics is rule based in that some actions are never

permissible, one example being lying and that some moral choices are not choices but

categorical and must be followed (Rachels, 1999). Acts or choices then would have to be viewed

through what should be done and what choices would be acceptable by everyone, which if

acceptable to everyone are then according to Deontological ethics called universal maxims

(Rachels, 1999). If a personalchoice could be universally acceptable by a community as to be

considered for a law that they could follow themselves, then that person should go ahead with

the decision (Rachel, 1999). Such a decision then would be considered a good act under

Deontological ethics (Rachels, 1999). Such a person¶s actions would be considered good because



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the community would view the decision righteous (Rachels, 1999). Therefore, with a practitioner

who is debating the self-disclosure of an error, Kantian ethics would consider the withholding of

the information as a morally wrong decision. Utilitarian theory also would deliver the same

conclusion as Kantian ethics. The withholding of the truth is to say nothing, or a null occurrence,

which can be considered a lie of omission, is self-frustrating and not permissible under Kantian

ethics.

The clinician is independent and has free will, even though we may have differing

viewpoints of what is right regarding the issue at hand (Chambers &Wendel, 2005). The person

who committed an error unfortunately has the burden of deciding how the error came to be and if

he or she should report it (Chambers &Wendel, 2005). Reciprocity may be involved in such

situations because honesty is what we would wish if an error had occurred to us (Adler et al.,

2006). If the nurse views her personal medication error from the standpoint of reciprocity then

she might report an error, picturing herself as the patient who received the error. According to

Adler, Russell & Proctor in the book, Look ing out, Look ing in, reciprocity is most often

associated with people whom we do not know (2006). This matches the stance of utilitarianism

as to why a nurse or doctor would reveal information about a sharp-end error. Both reciprocity

and utilitarianism can be so strong a motive that even if the nurse viewed the medication error as

systemic in nature he or she may still report the error.

Each person is affected through time and experience by many life situations. Every day

we make a multitude of decisions, many small and others more significant. Many of the

decisions we make through the day are routine and decided on without much thought. Some of

these routine decisions can be overlooked but can at times have disastrous consequences if



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compounded by other non-routine events. In hospital-settings, routine decisions can quickly turn

into life altering events for the patients and the nurses. Because routine decisions in hospitals

can turn into tragedies, the staff of hospitals must be trained in ethics and should be provided

with an ethical decision map that will point them toward an appropriate resolutions should a

tragedy occur. In order for us to have good logic and reason in making decisions, we must be

trained in virtues and by the building up of our personal character (Bluhm et al., 2007). We

should make decisions as the facts have presented themselves to us and with prudence (Bluhm et

al., 2007). Morality and virtues are also definitions of what makes up a value system. Morality

and virtues make up our personal morality and can be stated by quantitative questions directed

toward others, such as asking a person, ³What do you believe is the good and the morally just

thing to do?´

One of the foundations of American society is that of spiritualism and the belief of divine

authority. In America the dominate religious are Christianity, Judaism, Islam, and Hinduism.

Each of these religions believes in a divine supernatural authority. It is this belief in a

supernatural divine authority that gives rise to personally held values of faith. Personal faith in a

divine authority and in laws that are to be attributed to that divine authority for which we are to

follow can besummated in the divine command theory. Therefore, according to the divine

command theory what is right is acceptable and pleasing to God, the opposite of which being

what is wrong is not acceptable and so is distasteful to God (Rachels, 1999). According to the

divine command theory, we have free will to choose to obey Gods laws or to reject those

(Rachels, 1999). If we willingly and consistently violate Gods laws however, after we die

punishment will incur because of those continual violations of divine authority (Rachels, 1999).

The impetus here is that what is right by God is commanded and as such can be seen through



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human social growth, the stability of our cultures and to some extent standards by which we treat

one another (Rachels, 1999). For a clinician anything from a cursory knowledge of any one

religious perspective, religious concepts or laws that promote human value, to deeply held

beliefs can provide a system of virtues that can influence the self-reporting of an active error.

Divine law and natural law are not exclusive but can entwine in such a way that enhances

feminism and the ethics of care. In addition, divine command theory, natural law, utilitarianism,

deontology and Hobbes social contract can form a framework that provides societies value

systems for rule making, hierarchy of authority, and punishment/reward structures.

The natural law theory states that the world is ordered in such a way that each entity has a

purpose and is a sub-set of another entity such that these entities form systems and are rational.

These rational entities form a hierarchy that not only forms our observable universe, but also in

the fact that if one could have it that way that is the way one would wish it to be (Rachel¶s,

1999). One example of natural law is the explanation of why humans are communal and live in

communities. Natural Law theory would explain that we are communal because being communal

offers beneficence us, which is a positive survival trait for the Homo sapiens species (Rachels,

1999). Communal type benefits are encoded in our biology as it is in the Mammalia and Order

Primate to do so. Another example of natural law theory is its ability to explain why we as

humans care for one another. We care for one another because it allows for complex cooperative

tendencies, which can be found particularly in the Primate Order. These traits offer us for

example, the benefits of protection and the ability to gather food. Because of our communal

tendencies, the division of labor can occur with our species. With natural law, we would tend to

care for others, protect the young and elderly and offer help to the sick because it is in are

genotype. Natural law theory could work as an ethical value system to promote error reporting



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for the care of the sick. Natural law theory could also be used as a reason to not report a self-

error to provide protection of the nursing cohort.

Feminism as an ethical theory is split into two defining eras, the 1960¶s and early 1970¶s,

and the 21-century era (Rachels, 1999). Feminism birth it traditional form from the women¶s

liberation movement, its tenants being that no distinction of the sexes exists, or according to

Rachels, ³Nature makes no mental or moral distinction between the sexes´ (pg. 162). Over time,

feminist thinkers have moved Feminist theory from no distinction between the sexes to

differentiation between men and women, but beyond male traditional societal dominance to a

greater over all equality (Rachels, 1999). Twenty first century feminism accepts typical

differences between men and women, but modern feminism proposes that men and women are

equal in status and morality (Rachels, 1999). Currently, feminism proposes the ethical notion of

care through close relationships that are inherent to women more so on average than men

(Rachels, 1999). We can then conclude roughly that the decision to report an error could be

effected by the values of care or rule depending on the sex of the clinician. Therefore we can

assume on average a feministic or an ethical virtue of caring would be more likely to develop

between a female nurse and her clients such that a feudatory or advocacy role would be adopted

between them (Callahan, 1988). If this is so, the values of feudatory responsibility and the ethics

of feminism would give a strong prompt to self-disclose an error that the nurse had made.

We live in a world of limited resources. This limited supply of resources force

communities to make social choices deciding which persons in that community get which

resources (Cochran & Malone, 2005). When scarcity forces the public to make choices with its

resources, the public interest is engaged, which then deliberates so a consensus on how to deliver



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goods and services to its people can be made (Cochran & Malone, 2005). In modern democratic

societies, this course of consensus building and resource allocation decision-making is titled the

public policy process. The public policies main task is to develop rules that a society can agree

on so that some of its needs are met (Cochran & Malone, 2005). In order for a healthy society to

function many times, a person¶s self-interest is placed aside for the social responsibility of others

(Cochran & Malone, 2005). When societies work through the public policy process and

agreements on where resources should go, social contracts are then made. These new social

contracts are then enforced by that society to dictate how those resources are to be shared among

its population. The ethical theory of social contracts is an attempt to explain why societies

function they way they do and how our personal interests can be shifted from self-centeredness

to empathy.

One explanation of how social responsibility is formed is through the ethical theory of

Hobbes Social contract. Hobbes social contract theory is an ethics based approach for

understanding our value systems through agreements with one another. Hobbes social contract is

an attempt to explain how we as society deal with the practical problem of choosing between our

self-interests and the public¶s interest (Rachels, 1999). The ethical theory of Hobbes social

contract attempts to explain how our values came to incorporate the social rules of life we have

in existence today (Rachels, 1999). Hobbes social contract proposes that our values come not

from God or altruism but from the cooperation that we as people accept to escape the state of

nature, otherwise known as survival of the fittest (Rachels, 1999).

How do we justify the obvious fact that governments (Cochran& Malone, 2005) right

down to health care organizations exercise authority over us as individuals? Why have we ceded



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some of our own personal autonomy to the council of others? What would be a compelling

reason for this fact? It is obvious that our own self-interests at some point will clash with others

self-interests with the result being that compounded by many people a consensus on what would

be acceptable as social order might never result (Cohran& Malone, 2005). Hobbes has brought

this up by proposing what life would be like without authority and a means to impose

cooperation on us. If there were no laws, no authorities, no social rules, no way to enforce order,

no courts, no police and everyone could go and do as he or she wishes, what would the world be

like (Rachels, 1999)? Hobbes answers this question by stating that life would be violent, brutish

and short, no one would live in peace, everyone would live in fear and want, be alone, live in

constant danger, without culture, without advanced knowledge and with no accounting of time or

meaning (Rachels, 1999).

Under Hobbes state of social chaos, no one could exist beyond a young age; death would

come unexpectedly, death often quick and violent (Rachels, 1999). Therefore, in order for us to

survive as a species we would need to give up some of our self-interests for the groups benefit

(Rachels, 1999). In order for us to give up some of our self-interests for the benefit of society

there would need to be an agreement made that we would not attack or hurt each other, only then

would people feel safe enough to give up some of their self-interests for the group (Rachels,

1999). In addition to agreements with one another, we would also need to keep those agreements

and promises with one another (Rachels, 1999). This can only occur by making suitable

consensus rules and establishing an enforcer of those rules, a government for example (Rachels,

1999). Anything resembling an agreement between two or more parties and an enforcer of that

agreement between them is labeled a contract. Within the context of society, once laws are set in

place and a government is established in power to enforce these laws, Hobbes states a social



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contract is then formed (Rachels, 1999). According to Hobbes social contract, only under these

civilized rules do we have the safety and the allocated resources to be kind enough to give

resources to one another (Rachels, 1999).

It is the researcher¶s opinion that what makes Hobbes social contract theory so important

to policy analysts is that it offers a more complete picture about why people follow rules. This is

not to say that utilitarianism, deontology, feminism, natural law or divine law theories do not

have their place in our value system, but this researcher believes they are set within the context

of Hobbes social contract. These ethical theories enrich our social contract but they cannot

replace our social contract. Without order in our society other ethical theories could not develop.

Order is needed for higher value systems to develop, without order the others would possibly not

exist. It is Hobbes social contract theory that offers the most promise toward furthering the ethics

of medication error reporting. Hobbes social offers the most promise toward furthering the ethics

of medication error reporting because Hobbes social contract allows for guarantees and trust to

be developed between people and organizations. With guarantees and trust comes the acceptance

of a standard method of an action, the majority state of what is considered proper and just by the

people. A new balanced social contract built into our error reporting systems would foster trust in

a system where previously the consequences of reporting a personal medication error were

unknown.



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The unification of ethics and EHR systems

In an article by Robert Davis titled, A win/win for the public¶s health when administ r ative

and clinical data standar d mer ge- A New York case study for an integ r ated emer gency

depar tment data collection system he writes, ³that trust will ultimately determine the success or

failure of this project or any future projects´ (pg. 3). The statement by Davis was on the design

of New York¶s EHR project. Trust must be shown through outreach, in this thesis towards nurses

(Davis, 2003). Again, Hobbes social contract of rules, trust and enforcement integrate well with

the many competing factions found in our US health care system. Ethics can be incorporated into

information systems design and the training of clinicians, but also in error reporting for the

health care industry in general. Standard ethical theory must be integrated into our healthcare

system because in this era of rapid change we are confronted with many types of new and

unfamiliar health care situations that did not exist before, yet still we must make a moral decision

when required (Blum &Heineman, 2007). The established principles we live by in everyday

society must then be extended into the realm of these new and unfamiliar healthcare situations

(Bluhm et al., 2007). Regarding this end EHR systems parallel our need for ethics to be

incorporated into the healthcare industry because according to Davis, ³the complexity of our

world today makes it no longer possible to answer all [our] critical questions«or for that reason

alone it is necessary that we design an integrated system´ (pg. 2).

In a report on the implementation of a state-wide EHR system in NY which eventually

would replace earlier local efforts, Davis goes on to report that the incorporating of trust,

outreach and legal protection into the standards of NY statewide EHR systems as to the means



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by which they were successful (Davis, 2003). This altruistic/trust context Davis cites correlates

well with Hobbes social contract. This trust context is also outlined by James Rachels, in T he

Elements of Mor al P hilosophy 3r d

Edition, which encompasses social contract guarantees,

incorporates dependence agreements, assurance, beneficence, rules, mutuality, and trust

(Rachels, 1999). Therefore, ethics can and should be integrated into the designing of EHRs, the

error reporting systems used by healthcare organizations and integrated through the training of

those who must make most of the clinical decisions in hospitals (doctors, nurses, pharmacists,

technicians).

Those that make clinical decisions in hospital include doctors, nurses, pharmacists,

technicians, administrators and the board of directors. In order of a hospital to function,

consensus building must occur along with an agreement between parties of how work functions

are to be performed. Work functions within a hospital also included the EHR/HIT systems

clinicians utilize at their job site. In order for doctors and nurses to perform work in a health care

setting, as proposed by Hobbes social contract theory consensus building and trust are necessary.

If we require a group¶s consensus to perform advanced work then ethics must apply to all those

people and things that make up hospitals culture. According to Hobbes trust must apply to any

organizational entity that has within it contracts based on trust and enforcement otherwise there

could be no culture or organization. What is faulty is the ethics of the healthcare settings social

contracts between its employees and its administration, its employees and regulatory bodies. If

this is so, then Hobbes suggest as mentioned before that a new social contract must be

established, or the ethics of just cause. Ethics should be a greater part of EHR systems. If each

part of a culture such as healthcare, to function must have order and consensus then ethics must

be applied to each of its components to meet it. In addition to the modification of ethic between



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employees and employers in healthcare so to then EHR/HIT systems and their design must

include ethical values. A model for error reporting must then be developed in order to effect the

value systems in place that are now within hospitals allowing medical errors to increase at

unprecedented rates.



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The unification of an ethics based approach to EHR and error reporting

In the case of New York States integrated Emergency Department Data collection

system, commonality between constituents was required (Davis, 2003). Outreach toward all the

constituents whose cooperation, input and buy-in would be required for the statewide EHR to

work took time to develop trust between those developing the statewide system and the

stakeholders (Davis, 2003). Nurses, doctors and other clinicians do not work alone; they work in

the systems they are hired into. They work together in work groups with structural and

organizational properties (Cummings & Cross, 2003). In New York¶s case, in order for the new

EHR system to work, those in charge of creating the system required establishing trust with

administrators, doctors and nurses (Davis, 2003). A coalition was needed to push the stateside

EHR initiative along and then those coordinating the creation of the new system had to support

that coalition (Davis, 2003).

Health care employee groups, in this writer¶s opinion are, by nature of the work itself

hierarchal in structure along with its supporting administration. Keeping this in mind and

referencing back to Hobbes social contract, both human and information systems thus resemble

contractual agreements such that they are rule based, are organized and have hierarchy, have

controls built in, function through communication and follow a regulatory process that is

facilitative. Therefore, with any social contract we wish to understand we must define what

organizational system has been set in place within a hospital, whothere are enforcers and who

communicates the rules of that organization to those who work there. Based on the assumptions

above we can create two models of the same contract that exist in health care as present, one



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human and one informational. The potential models that are assumed to exist in hospitals are

shown below in figure 1 with their social/contractual obligations highlighted.



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Figure 2



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According to the proposed social contract model in figure 1 above, the Board of Directors

of a health care facility and the EHR modeling group are contractual guarantors, they have the

obligation and authority to appoint rule makers for others to create the rules that hospitals need to

operate. In both the corporate organizational model and in the EHR model, the CEO agents and

domain experts are those authorized to make rules that others must folow. In the proposed

organizational model, the vice presidents of a health care facility are action oriented and enforce

compliance, while clinical supervisors are the mediators between those who must obey orders

and their enforcers. In this proposed social-contract model, clinician staff are those whom agree

to follow the social contract within their health care facility, doing so by choosing to be

employed there.

With information system models artifacts and class analysis rules are created, model

tasks, modeling vocabulary and relationships then define how the created rules are to be

followed and by what people. Relationships in an information system allow for the enforcement

of rules and so can be considered rule enforcers, facilitate the creating of an EHR system.

Stakeholders and domain experts cooperate to follow the enforced ruled to finish building a

contracted EHR. Even though the rules in both organizational systems and informational systems

are enforced, the rules established to follow rules, as in Hobbes social contract theory are

voluntarily agreed to. Hobbes defined the contract as voluntary when he cited civil insurrection

as a willful overthrow of the enforced social contract (Rachel¶s, 1999). If there is no rejection of

a social contract then by default it is agreed to by those who do not reject it. Likewise, this too

can be seen when the staff of a hospital walks out on strike or when stakeholder buy in does not

occur during information system modeling.



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Since Hobbes social contract aligns with both the organizational structure of a hospital

and the act of system information modeling, how then does Hobbes ethical theory help with error

reporting? Hobbes social contract identifies what key areas trust must be established and

indicates the motives as of why medication error reporting has been so lax. It shows through

theory not in a legal sense but in a societal form, we agree to be civil and follow law not because

we are legally bound, but because we legally bind ourselves to escape social chaos. In health care

constituents need to define what is considereda violation of their social contract, what needs to

be changed for a decline in medication errors and for there to be an increase in reporting errors to

occur. Unfortunately, nurses must agree to the current set of social rules that exist in their places

of work because there is no other alternative at this time, unless they disenfranchise themselves

from the healthcare system. In addition, Hobbes points to the emotional more value centered

person and how his or her values and their rational mind can be over-ridden, replaced by the

need for personal preservation. Hobbes social contract points out what rules must be established

in a hospital setting, its clinical guidelines and how teamwork should be socially defined. Hobbes

social contract points out what is required to maintain the social contract between the

enforcement side and the acceptance side. Hobbes social contract also dictates when social

contracts become unattainable and can be broken such as in self-preservation. Hobbes social

contract defines a just culture of trust and fairness that can be extended (Joint Commission,

2005a) into information system modeling, error reporting and into health care organizations

themselves.

The board of directors must uphold the social contract for which clinicians have entered

into, namely to be employed in a safe and adequately staffed facility. The board must provide

adequate resources in order for the hospital in order for it to function at safe and efficient levels



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(Caffarini, 2009). Within health care organizations the board of directors must place patient

safety above all other goals (Joint Commission, 2005a). They must keep the CEO on target with

the reductions of malpractice incidents always in focus (Joint Commission, 2005a). The CEO

must guarantee or attempt to limit short-term gains for the long-term stability of her hospital

(Brewster et al., 2001). The CEO/CFO should attempt to balance her hospital¶s finances, limit

her ER overcrowding, limit the potential for her hospital to close and limit her hospital¶s

potentialfor a merger unless to do otherwise would be critical to the continued function of her

hospital (Brewster et al., 2001). Vice-presidents should be visible and approachable by staff, as

social contract theory demands such, that representatives who have appointed power over others

be available so the social contract cannot be manipulated from above or below that level in the

social contract. Vice-presidents should provide an atmosphere that medication safety is

everyone¶s responsibility to the staff supervisor and that safety is a core value throughout the

chain of command (Aspen, 2007). Clinical supervisors on a continual basis should inform nurses

and doctors that safety decisions are made at all levels, not just at the staff level (Aspen, 2001).

Supervisors should instill a value system of family-centeredness and one of empathy (Aspen,

2001) not of fear (Hohenhaus, 2008). Finally, staff should accept a ³just-cause culture´ and not a

system of blame (Rajasekaran, Fairbanks &Sheh, 2008).

However, nurses or other clinicians can only expect just-treatment when reporting errors,

if they believe they will get just treatment from reporting it and they will only believe it

themselves when they see just-treatment exercised over time. This ³just-culture´ will only exist

if enforced organization wide. What are the ethical theories this paper brings to the medication

error overview that other papers have not? Hobbes social contract highlights the lack of error

reporting is a personal decision based on morality and this morality is contract based (Rachels,



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1999). This contract-based morality extends not only to the staff of the hospital but to its

administrators and those who develop EHR systems for them to utilize. This paper shows that

staff enter into contracts by agreeing to work in health care agencies and that these contracts are

failing them, both written and socially unwritten ones. When a nurse enters into a contract to

work in a health care agency such as a hospital, more often than not, as the previous chapters of

this paper highlight, what he or she assumed would be the working environment there does not

exist. For a Nurse in such situations there must be emotional shock occurs because in many

instances the employment conditions they have to work within are poor. This paper highlights

the stress staff is continually under, the poorly designed EHR/HIT systems they must use, the

continual budget cuts they face, and the lack of autonomy they have when deciding decisions

about their own guilt or innocence. Nurses come to realize only after they are employed that the

contract they step into when they enter work has failed them. Hobbes social contract offers other

motives for not reporting a sharp error made by oneself then that of contract failure as other

papers view it, which would be as a legal breach and not as a social one. A social contract is as

every bit as binding as a legal one, in this authors opinion.

One could propose nurses do not report medication errors not only because of the fear of

reprisal, but also because they feel that the social contract they have entered into with the health

care facility has failed them. In this authors opinion the health care industry has taken a nurses

given authority and used it against them without their consent. A nurse¶s authority is as an

advocate, as a caregiver, as a utilitarian rule abiding fiduciary and as a moral elder. Morally

nurses must take their propensity to care and use it against themselves when they have created an

error that is a systemic fault. This must be extremely caustic to oneself, the profession and health

care in general. It can be seen then as doctors and administration against nurses, or ³an us against



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them´. Another example from Hobbes social contract theory is when the social contract between

those of power and the people fail, then civil unrest can potentially result (Rachels, 1999). Once

this occurs people seek self-preservation forgoing altruism or beneficence toward others. This

concept of self-preservation if applied to clinician errors and a failed health care contract would

cause nurses to seek self-preservation and not to report their error.

Rachels in his book writes, ³These rules (social contract rules) are necessary, justified

simply by showing that they are necessary, if we are to cooperate for our mutual benefit´ (pg.

152). Hobbes social contract theory shows that staff will not begin to apply a ³just-culture´ and

report closer to the actual numbers of errors occurring in a health care facility unless the health

care social contract is mended. Although nurses cede power to the system they work in, there is

little means to alter it once authority is lost. Again, Hobbes civil unrest is brought to light in this

instance (Rachels, 1999). Therefore, I propose staff is more passive than some other papers this

writer has reviewed suggest, because the health care system is rigid. A nurse to be employed in

the field he or she is trained for must work in that system, they cannot leave the nursing field

because they do not like the contract without having to train for another industry altogether. In

health care organizations, error reporting will increase and overall errors will decrease only when

trust is shown to staff and for staff then to reciprocate. Establishing trust takes time and effort

between the parties involved. The experience of a ³just culture´ has to be seen organization by

organization by its own employees, for the social dynamics of hospitals to change enough for

nurses to trust it and report their medication errors.



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The practice of Nursing, medication error and trust in error reporting

Trust is central to Hobbes social contract as opposed to rule-based deontology or act

based utilitarianism (Bluhm et al., 2007). Immanuel Kant, proponent of deontological ethics

viewed the world governed by universal laws (Bluhm et al., 2007). He also viewed us governed

by this universality such that we would not accept those laws which would be self-frustrating

(Bluhm et al., 2007). An example of two self-frustrating laws would be that of lying and of

stealing because trust between people would dissolve and no one would be able to lend or

borrow (Blum &Heineman, 2007). With medication error, a utilitarianism viewpoint would

propose telling the truth in all circumstances (Adler et al., 2006). Kant advocated telling the

complete truth regardless of the consequences (Adler et al., 2006) in this case a nurse of doctor

who has made a medication error.

In the book, Ethical Issues in Pr

ofessional Life edited by Joan C. Callahan brings into the

field of nursing another value system should be integrated into this literature review, that of

nurse as advocate. The viewpoint of the nurse as advocate is the final ethical theory needed to

show why deontologyand utilitarianism are not benefiting the health care industry in reducing

medication errors. Utilitarianism as well as the punishment for errors that it would suggest if

followed are not strong enough forces to push people toward compliance. Like deontology¶s rule

based moral laws and utilitarian¶s principle of utility or purpose (Rachels, 1999), facts are

important to the nurse as proposed by normative questions, but personal values also hold sway in

the decision making process (Callahan, 1988). A professional might chose to make a decision

based on economic or expedient values rather than on ones based on ethical values (Callahan,



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1988). Feminism holds that the ethics of care can be intrinsic to the genetic or environmental

influences of the female human gender (Rachels, 1999). Nursing would inherit the ethics of care

then because women in the US now dominate the field of nursing (Callahan, 1988).

On average because nursing field in the US is dominated by women, then they would on

average incorporate the ethics of care as well as the ethics of advocate/fiduciary as Callahan¶s

book proposes (pg. 87). What is important to note is that when the ethics of care, advocacy and

feudatory are integrated into the nursing profession, nurses take on the moral rights of the clients

that are under their care (Callahan, 1988). Nurses have over the last 30 years become

³courageous advocates´ as Callahan¶s book calls them, for the patient and at odds many times

against their own hospital (Callahan, 1988). Often nurses defend the patient but fall to influence

the system they work for, that can often overpower them (Callahan, 1988). Therefore, a strong

social contract needs to be in place, enforced through and around nurses, and not rule or act

based. If the relationship between nursing and patients is that of fiduciary and of covenant, then

Hobbes social contract integrates well with such as Callahan¶s theory. This is because unlike

deontological or utilitarian ethics, Hobbes introduces a social or communal tendency: for the

majority to agree on what we view as right or wrong for the sake of all to benefit, that our moral

values are not just rote yes and no responses to a preconditioned moral-dilemma.

Given Callihans proposal then a nurse who has made a medication error may report the

error, acting as a feudatory to the patient involved or withhold reporting the error seeing the act

of not reporting as advocacy against the system. Not reporting an error can be seen as a

protesting statement against the broken contract he or she is employed with. Hobbes social

contract extends the boundaries within the health care field by humanizing the values each



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An ethics based model of reporting error

So then what should a nurse do with the personal dilemma of reporting an error made by

himself? Should the nurse report any and all errors, even though the health care social contract

he or she is working under now is in need of drastic repair? Are some errors more important to

report than others are? Should some medication errors be confidential for the protection of the

nurse and/or patients benefit? Can the withholding of critical information benefit a patient or a

nurse? According to Callahan¶s book, Ethical Issues in Pr ofessional Life, the obligations of the

health care social contract between constituents are freedom, dignity, truth telling, justice and the

keeping of one¶s promises (Callahan, 1988). In her book,Callahan states that only though a

contractual model of trust can responsibility be shared among physicians, nurses, administration

and the patients (Callahan, 1988). Only by keeping trust among the constituents is the contract

valid, without trust and confidence the health care contract is broken and dysfunctional

(Callahan, 1988). If repeated violations of the truth occur in our health care system, confidence

in the system will fall (Callahan, 1988).

This researcher is suggesting the contract between the US health care system and its

employed nurses is broken. The presumed impartial trust between nurses, hospital administrators

and the regulatory agencies involved within healthcare is not enforced. The trust between the

nurse and the patient is considered strict and unbreakable; he or she is required to report all

inconsistencies in treatment whether or not there is any harm done. There are no options for a

nurse who has found herself involved with a medication error if she makes a medication error,



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then she must report it to state or federal agencies and the hospital administration even if outside

circumstances forced the error. Positive recourse is not offered in mandatory reporting even if

latent failures, staff cutbacks, or a toxic working atmosphere had been a major reason in causing

the nurse¶s mistake. If a nurse reports a personal error, she has the fear of losing her job and even

her license to practice. The logic of this situation is unworkable on the nurse¶s end. Until what

this researcher in the section preceding this one in the literature review, section C3 is

accomplished not much of an increase in error reporting will occur. The reporting of a self-made

medication error should be mandatory but with caveats based on the NCC MERP Index for

categorizing medication errors. In the book, Look ing outLoo

k ing in 12

th

edition, by Adler, Russel

and Proctor, the authors cites philosopher Sissela Bok¶s principle of veracity. According to Bok,

in Adler, Russel and Proctors book, ³the principle of veracity asserts that truthful statements are

preferable to lying, in the absence of special consideration«the telling of truth whenever

possible´ (pg. 324). The principle of veracity then is a temper of Kant¶s categorical imperative of

universality (Adler, et al., 2006).

In order for a person to decide if these ³special considerations´ are valid, Bok has

proposed the test of publicity. where if a majority of those not involved in a decision knew all

the facts of that situation in question, still would decide that lying is the best course, than lying

can be done for that situation (Adler, et al., 2006). It is important to note that this researcher is

not advocating lying about one¶s own medication error mistakes, if that were so, this thesis

would be unnecessary. However, in order to limit the ethical tension suffered by nurses as

presumed by Hobbes social contract and until the social contract between nurses, error reporting

and health care system is changed for the better, I propose a compromise reporting system for



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nurses. The compromise I am suggesting be adopted by healthcare facilities and their staff is as

follows:

1. Mandatory reporting of a medication error should be universal for all states using

the NCC MERP index when medication errors fall into the categories E, F, G, and H.

2. Medication error reporting should be optional for those errors that fall into the NCC

MERP Index categories of A, B, C, and D (³NCC MERP Index for Categorizing Medication

Errors´, 2001).

The distinction is that when categories A-D errors of the MERP Index occur no har mis

done to the patient while when E-I errors occur har m is done to the patient. Below is the NCC

MERP index schema for determining the category of an error and should be implemented in all

error cases, regardless of reporting.



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Figure 3



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Trust, anonymity and the goal of reducing medication errors in health care facilities

Finally, how are all those concerned about medication error supposed to deal with the

anonymity of a nurse who is reporting a medication error? It should be noted that the ethics

based model proposed in D1 of this paper includes the proposals in this section, because again

medication error reporting as we have seen in this literature review will be limited without

personal guarantees. T herefore, the ethics based approach I am proposing for error reporting

includes section D1 and this section D2

, in its entirety.Personal guarantees for those who have

to report an error will be the only way to reduce the fear of reprisals from reporting, without

which the reporting of errors will likely stay low. The two proposal sections D1 and D2must

becombined because error reporting and clinician fear of reporting are part of the same issue.

Clinical error reporting has been on the public policy agenda for years and this policy

issue as any other ultimately deals with people and their behaviors (Cochrane and Malone,

2005). According Cochran and Malone in their book, P ublic P olicy P er spectives and Choices 3r d

edition, they write, ³the public policy sciences deal with the behavior of people, which is not so

neatly categorized as other phenomena«However«one cannot conclude that the discovery of

relationships is impossible, only that there are more variables´ (pg. 40). Cochran and Malone

were referring to more variables in public policy analysis than in the sciences of biology,

chemistry and physics (Cochran & Malone, 2005). This position paper sought to capture the core

variables that are surrounding medication errors. This position paper sought discover and detail

the ethics surrounding those who are employed in the health care field and how a middle road

can incrementally shift current policy so that error reporting will increase.



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However, the security of the clinician that is reporting the error, finally has to be taken

into account. Although people have free-will and act on their emotions, that does not mean that

people do not think and often act on their values as well (Cochran & Malone, 2005). Emotions

affect human behavior, but that does not mean that people will not act rationally in a given

situation (Cochran & Malone, 2005). Although individually people¶s behavior can be difficult to

predict, collectively when the behavior of many people in the same situation are reviewed there

develops a consensus on how they will react (Cochran & Malone, 2005). We have seen this with

error reporting, in that although some self-made medical errors are reported system wide, many

are not because of fear of reprisal. Again the concept of appropriate disclosure has been brought

up by Robert Davis in his report, A win/win for the public¶s health when administ r ative and

clinical data standar d mer ge- A New York case study for an integ r ated emer gency depar tment

data collection system, where he writes, ³individuals claims to privacy must be balanced by their

public responsibility to contribute to the common good«[and should] be used with respect and

care´ (pg. 3). Davis also comments that reporting data should be legally protected (Davis, 2003).

Only what is minimally required to understand the error should be collected (Davis, 2003). As

the Joint Commission reports internet-based anonymous reporting is and can be done after a

sharp-end error occurs, when the clinicians returns home (Joint, Commission, 2005a). In one

example, the Joint Commission cites the Vermont Oxford Network and its internet error

reporting mechanism for their neonatal intensive care units (Joint Commission, 2005a). In the

case of the Vermont Oxford Network, once one of their health care professionals report an error

the information is reviewed by a team of experts and after recommendations to the facilities that

participate in the networkare issued (Joint Commission, 2005a). These recommendations are

issued to the originating error reporting facility without the error reporter¶s identity ever being



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revealed (Joint Commission, 2005a). What is most important in the Vermont Oxford Network

example is that because the information is submitted anonymously to begin with, anonymity is

not compromised and so would be difficult to breach (Joint Commission, 2005a).

In New York States integrated EHR, each hospitals patient data is transmitted from the

health care facilities with Secure Socket Layer technology 128-bit encryption to the New York

State Department of Health (Davis, 2003). The secured network allows access for a verified data

supplier to sign onto then network and transfer the data asynchronously or in each direction as

needed, sending and receiving the pertinent information (Davis, 2003). The New York State

EHR system uses a HIPAA security compliant database, which is then mapped at the receiving

end into software readable files for professional review (Davis, 2003). Although the New York

states Integrated Emergency Department Data Collection System does not process error

reporting per say, its main function being clinical patient data at the point of hospital entry, it

offers excellent insights on how error reporting should be applied nation-wide.

A nation-wide medication error reporting system should keep its information secure.

Reporting should be from the clinician¶s home through a secure web connection, preferably 256-

bit, as this is the standard with online banking transactions as of the writing of this thesis.

However, security does not mean anonymity. Although reports can be presumed to be

anonymous when one reports an error or engages in any online activity from a home computer,

every computer, printer and most new cellular devices have unique identifiable numbers. In the

case of computers, each one at the time of manufacture has a permanently assigned MAC

address. Once the person links the pc to another network device or the internet, a unique IP

address is assigned. These individual computer addresses can be logged by a simple IP address



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search and then geo-located tracked right to the location of the error reporter¶s home location.

Therefore, because I am proposing a nationwide error reporting system and a long-term

infrastructure investment, I propose that the home user login through a distributed network of

proxy IP servers. These servers should be established by an appointed third party and as such

only utilized by the national error reporting system, this way the end site cannot be faked by

malfeasance and the original location would not be found. The proxy servers would then connect

to the national reporting system database. Furthermore, if a person is required to report a

personal error, logging into the proxy network should require a key code generator such that

when a button on the key is pressed, a sequence of numbers based on the internal rules of the key

are displayed. Each time the key is pressed new numbers would cycle through and would be

required with a personal password to log into the proxy network. For an example of number-

generating key tags see the figure below. The keys and a personal temporary password would be

assigned to the nurse or doctor upon employment.

Figure 3 Figure 4

Figure 5



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clinician after following the above mentioned steps would then continue through the proxy

network into the national database. Once logged into the national database a questionnaire

similar to the developed from the NCC MERP taxonomy list would be answered by the clinician,

generic enough in nature as to not show the location of the logged in clinician, the patient or the

health care facility involved. Once the questionnaire has been completed, the clinician would exit

the national database, the proxy network would then automatically disengage the database and

his or her computer and the nurse could then continue with his or her other tasks.

Various national, state and local error-reporting systems and are in use, this researcher

goal was to introduce new concepts into the reporting of errors and perhaps propose theories that

may be of use to the ethical, medical, pharmaceutical, and medical information technology

fields. No doubt in some of these cases these concepts are a review, in others perhaps new. The

goal of this researcher was that this paper enriches the fields mentioned above and adds to the

growing body of literature on error reporting. In summary of D1 and D2ofthis paper, the

following chart is an overview of the complete national mandatory ethics based error reporting

system proposed by this researcher. If any part of this text has been valuable to the reader, may it

enrich you and may it prosper you to the greatest extent.



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Figure 6



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References

Active Error.(2007). Clinician's Handbook of Pr eventive Ser vices.Agency for Healthcare

Research and Quality.

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