Medication Errors

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• Medication Errors
• Risk Reduction

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How do you define a medication error?

• any preventable event that may cause or lead to
  inappropriate medication use or client harm while
  the medication is in the control of the
  healthcare professional, client, or consumer.
• Definition from the National Coordinating Council
  for Medication Error Reporting and Prevention
  (NCC MERP)

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Why are medication errors such a concern?

• Because a shocking number of patients die every
  year in United States hospitals as a result of
  medication errors, and many more are harmed.
• Medication errors are the fourth to sixth leading
  cause of death in America.
• Medication errors are the most common cause of
  morbidity and preventable death in hospitals
  today.

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What are key factors contributing to
medication errors by the health care provider?

• Many new drugs on the market
• Distractions/Interruptions
• Understaffed facilities/overworked nurses
• Wrong med, dose, patient, route, time.
• Omission of dose
• Discontinued meds at D/C misinterpreted
• Misinterpretation
• Miscalculations
• Lack of clinical evaluation/assessment

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Who are the collaborative partners
in medication administration

• Prescribers
• Pharmacists
• Transcribers/Clerical Staff
• Nurses
• Patient / Personal Caregivers

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Types of Medication Errors

• Prescribing error
• Omission error
• Wrong time order
• Unauthorized drug error
• Improper dose error
• Wrong dosage-form error
• Wrong drug preparation error
• Wrong administration technique error
• Deteriorated drug error
• Monitoring error
• Compliance error
• Other errors not classified above

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Common Causes of Medication Errors

• Ambiguous strength designation on labels
• Drug product nomenclature ( look/sound alike)
• Equipment Failure
• Illegible handwriting
• Improper transcription
• Inaccurate dosage calculations
• Inadequately trained personnel
• Inappropriate abbreviations used in prescribing
• Labeling errors
• Excessive workload
• Medication unavailable

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Reduction of Medication Errors- Planning

• Use only approved abbreviations
• Question unclear orders
• Do not accept verbal orders unless emergency
  (repeat back for clarification)
• Follow agency policy and procedures
• Ask for client participation provide medication
  education
• Be familiar with the medication ordering system
  and delivery devices
• Always review patients medications with respect
  to desired outcome
• Verify all drug orders prior to initial dose
  administration.
• Provide medications on time
• When standard dosage charts are not available
  have a second nurse check the drug calculations
• If a large dose is ordered more than 2 tablets,
  ampules or vials this should raise a flag!
  Consult with Pharmacy!
• Listen to the patient hold if they have concerns
  and double check the order
• NEVER!!!! Give any medication prepared by another
  nurse (You should prepare all medications that
  you administer this is the only way to be 100
  sure of what medication you are administering).

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Reduction of Medication Errors- Implementation

• Assess
• Food or medication allergies
• Current health concerns
• Use of OTCs and herbal supplements
• Adverse reactions
• Review
• Recent laboratory tests
• Recent physical assessment findings
• Identify
• Need for education about medication regimen

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Reduction of Medication Errors-Implementation

• Be aware of potential distractions
• Remove distractions if possible
• Focus on medication administration task
• Practice six rights
• Maintain knowledge of medications and dosage
  calculations
• Always have another nurse re-check your drug
  calculations

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Reducing Medication Errors in Health Care
Facilities

• Methods
• Automated, computerized, locked cabinets for
  medication storage on client-care units
• Risk management departments
• Collaboration with nursing to modify policies and
  procedures

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Reporting and Documenting Medication Errors

• Document and Report according to agency policy.
• Report the medication error with an incident
  report.
• In relation to the associated legality, why is
  documentation of the error important?
• Quality Improvements
• Addressed in the 2011 National Patient Safety
  Goals Address NPSG.01.01.01 03.04.01,03.05.01,
  03.06.01

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Agencies that Collect and Report on Medication
Errors

• FDAs MedWatch
• Institute of Safe Medication Practices (ISMP)
• MedMarx

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Nurse Practice Act and Standards of Care

• The Nurse Practice Act serves as a minimal
  guideline to determine what a nurse should or
  should not perform to ensure safe and competent
  care.
• A medication error may be considered negligence
  and involve an investigation from the NC Board of
  Nursing and possibly result in a revoked licensed
  to practice as a Registered Nurse.

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How will you ensure that you will administer
medication safely?
Your patients and their families will be
depending on you.