chapter 5: Medication Error Flashcards
Which statement most clearly defines an error in drug administration?
Preventable event that leads to inappropriate drug use or patient harm
A drug administration error occurred; after investigation, it was determined the error was category D. Which statement accurately describes the error?
An error occurred that resulted in the need for increased patient monitoring but no patient harm
A nurse administers metoprolol 100 mg to a patient with hypertension but does not check the patient’s apical pulse before administration. The patient develops bradycardia, becomes dizzy with standing, and falls, resulting in a fractured lumbar vertebra. Which process of drug delivery does this involve?
Monitoring
Drug administration errors can result from which factors in the process of drug administration?
Drug administration errors can result from which factors in the process of drug administration?
1.Human factors
Drug administration errors may result from human factors (e.g., poor equipment design).
2.Individual factors
Drug administration errors may result from individual factors (e.g., failure to adhere to the five-plus-five rights).
3.System-level factors
Drug administration errors may result from system-level failures such as understaffing.
System-level failures leading to drug administration errors include which factors?
Heavy workload
Distractions
Fatigue
Computerized health care provider order entry in place of handwritten orders is an example of which strategy for preventing errors in drug administration?
Transcribing
Six RIGHTS for Nurses
- Right to a complete and clear order.
- Right to have the correct drug, route and dose dispensed.
- Right to have access to information.
- Right to have policies to guide safe drug administration.
- Right to stop, think, and be vigilant when administering drugs.
Just Culture
Encourages health care personnel who make errors to report them.
Culture of safety
Encourages everyone in the organization to keep patients free from harm
Sentinel event
Unanticipated event that results in death or serious harm
Root cause analysis
Identifies opportunities for learning
A drug administration error occurred resulting in myocardial infarction; after investigation, it was determined the error was category H. Which statement accurately describes the error?
An error occurred that resulted in a near-death event.
“An error occurred that resulted in a near-death event” (e.g., anaphylaxis, cardiac arrest) is category H.
A nurse listens to the patient’s lungs before administering albuterol for asthma control. The nurse notes wheezing on expiration. After drug administration, the nurse checks the electronic health record (EHR) to see what the patient’s lungs sounded like last shift before the administration of the drug. Nothing is noted. Which process of drug delivery does this involve?
Documenting
In this case, a documentation error occurred when the nurse on the previous shift failed to document pre-administration assessment.
The nurse caring for a patient receiving cisplatin notes extravasation of the intravenous (IV) fluid when the patient reported IV site pain. Even though the antidote (sodium thiosulfate) to cisplatin was administered, the patient experienced extensive tissue necrosis around the insertion site and required multiple skin grafts. Which feelings might the nurse experience after the drug administration error?
Self Doubt
Suicide Ideation
Posttraumatic stress disorder (PTSD)
The electronic health record indicates that a patient’s continuous infusion of heparin intravenously was to be stopped at 1000. At 1900, the nurse notices that the heparin is still running. Which type of error in drug administration is this?
Wrong dose
After 10 hours on the job, a novice nurse struggles to program the intravenous (IV) pump; to avoid hanging the IV drug late, the nurse decides to let the drug run in by gravity, after calculating the drip rate then adjusting the roller clamp on the tubing. Which individual factors set the situation up for a drug error?
Long workdays
Difficulty using equipment
Clinical experience of the nurse
The nurse draws up insulin into a syringe and calls across the nurses’ station for a coworker to double-check. The second nurse, who is charting, looks up from across the room and says, “It’s okay”; the first nurse notes the initials for the second nurse in the electronic health record (EHR). In this situation, which factor may contribute to an error in drug administration?
Human factors
Technology “work-arounds” (entering the second nurse’s initials into the EHR for them) fall under the heading of human factors.
Which orders are written inappropriately according to the Joint Commission’s official “Do Not Use” list?
- Digoxin .25 mg PO daily
- Mirtazapine 15.0 mg PO every day at bedtime
Which statement describes how drug errors are addressed in a system that operates according to principles associated with Just Culture?
Individuals are encouraged to report drug errors so that the system may be repaired.
Issues Contributing to Errors
Errors can occur during any step of medication process
* Procuring
* Prescribing
* Transcribing
* Dispensing
* Administering
* Monitoring
* Organizational issues
* Educational system issues
* Sociologic factors
* Use of abbreviations
Near Miss
- Event or situation that did not produce patient injury, but only because of chance
- Must still be reported so that safety issues can be addressed, and future incidents are prevented
Types of Medication Errors
- No error, although circumstances or events occurred that could have led to an error
- Medication error that causes no harm
- Medication error that causes harm
- Medication error that results in death
Strategies to Minimize Errors
- Awareness (“speak-up”)
- Computerized prescriber order entry (CPOE)
- Bar codes and scanning devices
- Automated dispensing machines
- Effective communication
- T.A.C.I.T.
Preventing Medication Errors
- Prescribers must write legible orders that contain correct information
- Nurses need to always check the medication order three times before giving the drug.
- The Rights of medication administration should be used consistently
- Two patient identifiers
- Do not administer if you did not draw up or prepare yourself.
- Minimize verbal or telephone orders.
- Repeat order to prescriber.
- Spell drug name aloud.
- Speak slowly and clearly.
- List indication next to each order.
- Always verify new medication administration records.
- Read labels carefully.
- Use generic names to avoid sound-alike trade names.
- Always listen to and honor any concerns expressed by patients regarding medications.
- Check patient allergies and identification.
- Know where to find information on medications, preparation, side-effects; Use only current sources.
- Mandatory second nurse verifications for high-risk medications and/or patient
population - Minimize interruptions when preparing/delivering medications.
Preventing Medication Errors
(continued)
- Never use a “trailing zero” with medication orders.
- Do not use 1.0 mg; use 1 mg.
- 1.0 mg could be misread as 10 mg, resulting in a 10-fold dose increase.
- Always use a “leading zero” for decimal dosages.
- Do not use .25 mg; use 0.25 mg.
- .25 mg may be misread as 25 mg
Reporting Medication Errors
- Report to prescriber and nursing management.
- Document error per policy and procedure.
- Factual documentation only
- Medication administered
- Actual dose
- Observed changes in patient condition
- Prescriber notified and follow-up orders
- External reporting of errors
- United States Pharmacopeia Medication Errors Reporting Program
- MedWatch, sponsored by the Food and Drug Administration
- Institute for Safe Medication Practices
- The Joint Commission or other accreditation agencies
Medication Reconciliation
The process of making sure the hospital’s list of a patient’s medications matches what the patient is actually taking.
Computerized Provider Order Entry (CPOE)
Allows MDs to electronically enter and send treatment instructions for patients.
This includes medications, labs, radiology tests
High Alert Medication
Drugs that can harm patient when used with error.
