CH 7: Med errors and risk reduction Flashcards
medication error definition
any preventable event that may cause or lead to inappropriate medication use or patient harm
while the medication is in the control of the health care professional, patient, or consumer.
Such events may be related to professional practice, health care products, procedures, and systems,
including prescribing, order communication, product labeling, packaging, and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring, and use.
Factors contributing to medication errors by healthcare providers include:
Omitting one of the rights of drug administration Common errors include giving an incorrect dose, omitting an ordered dose, and giving the wrong drug.
Failing to perform an agency system check. The pharmacist and nurse must collaborate on checking the accuracy and appropriateness of medication orders prior to administering drugs to a patient.
Failing to account for patient variables, such as age, body size, and impairment in kidney or liver function. The nurse should always review recent laboratory data and other
information in the patient’s chart before administering medications, especially for those drugs that have a narrow margin of safety.
Giving medications based on verbal orders or phone orders, which may be misinterpreted or go undocumented. The nurse should always follow the healthcare agency’s policy when accepting verbal or phone orders, many of which require the provider’s signature
within 24 hours.
Giving medications based on an incomplete or illegible order when the nurse is unsure of the correct drug, dosage, or administration method. Unclear orders should be clarified with the prescriber before the medication is administered. Written orders should avoid
certain abbreviations that are frequent sources of medication errors
Practicing under stressful work conditions.
Patients, or their caregivers, may also contribute to medication errors by doing the following:
Taking drugs prescribed by several practitioners without informing each healthcare provider about all prescribed medications
Getting their prescriptions filled at more than one pharmacy
Not filling or refilling their prescriptions
Taking medications in incorrect doses, at the wrong time of day, or otherwise not following the prescriber’s instructions
Taking medications that may have been left over from a previous illness or prescribed for another person.
most common cause of hospital morbidity and preventable death.
medication error
Health literacy includes:
what drugs to take
how to take them
Barriers for patients
Language
Navigating the system
When and who to call for questions
Measuring units
documentation of med error should include:
specific nursing interventions that were implemented following the error to protect patient
safety, such as monitoring vital signs and assessing the patient for possible complications.
document all individuals who were notified of the error.
How to report the error
Written report – this becomes your side of the story
Report in a factual, objective matter
Document factors that may have contributed to the error
strategies for reducing the errors:
assess - always first
plan
implement
steps in assessment:
o Allergies
o Current health concerns
o OTC medication
o Supplements
o Correct dosages
o Body system assessment – that will affect pharmacology
steps in planning:
o Avoid using abbreviations
o Question unclear orders
o DO NOT accept verbal orders
o Follow policies and procedures
o Teach back understanding
steps of implementation:
o Eliminate distractions – distraction is a KNOWN cause of medication errors
o ID patient
o Use correct techniques for the routes of administration
o Calculate doses correctly
o Double check with colleague for high risk drugs and pediatric drugs
o Confirm patient can swallow
o Never leave medication at the bedside
o Watch for LA, XL, XR – do not crush or split
o Watch for look-alike and sound-alike names
o Evaluate
o Assess for expected outcomes
o Assess for adverse effects
