Chapter 6 - Medical Errors and Risk Reduction Flashcards
1
Q
Medication errors
A
Any preventable event that may cause inappropriate medication use or harm
- May significantly impact rx outcomes
2
Q
Medication error index
A
- NCC MERP (National Coordinating Council for Medication Error Reporting and Prevention) developed
- Evaluates and categorizes medication errors by evaluating the extent or harm an error can cause
3
Q
Sentinel event
A
- The Joint Commission
- A risk to patient safety that is so great it could cause death, perm harm or severe temp harm
- Both sentinel events and near misses categorized as patient safety events
- Joint Commission requires review
- Changed term to patient safety event to include “near misses” - event, incident or condition that could have resulted or did harm
4
Q
Medication Errors - Scope of the Problem
A
At least 50% Americans take at least one prescribed medication; 17% take at least three prescribed medications.
- Medication Errors may….
- Extend length of hospitalization
Increase medical costs for patient, agency - Create legal challenges
- Extend length of hospitalization
- No acceptable occurrence rate
- All errors should be investigated
- Nurse need to avoid being distracted when giving meds
5
Q
Factors Contributing to Medication Error
A
Inadequate communication, or confusing labels, packaging, or drug names
- Majority stem from human factors
- Errors in patient assessment (no ID check)
- Inaccurate prescribing
- Errors in administration (error in dose calculation)
- Most errors involve one branch of the cardinal “five rights” of medication administration.
- Right patient, drug, dosage, route and time
6
Q
Medication Errors - Agencies and Reporting
A
- Studying types and causes of errors allows agencies and facilities to design ways to prevent them.
- FDA - works with health care agencies to determine necessary changes
- Institute for Safe Medication Practices (ISMP) - 23 National organizations
- Founded in 1994 to help standardize medication error reporting systems
- Promotes education
- List of error-prone abbreviations, symbols, and dose designations
7
Q
Medications with greater error rate
A
- Look-a-like or sound-a-like drugs
- ISMP publishes a list of confused drugs that recommends to Use “Tall Man Letters” as a method to reduce chance one drug will be mistaken for another (buPROPion vs. busPIRone)
- Drugs with a narrow therapeutic index more likely to cause serious consequences.
Top 5 High Alert Medications by ISMP study include :
- Insulin
- Opiates
- Intravenous Potassium
- Intravenous Anticoagulants (Heparin)
- Sodium Chloride Solution > 0.9%
Lists of high-alert medications should be posted on each unit.
8
Q
Reporting Medication Errors
A
- It is always the nurse’s responsibility to report and initiate live-saving action
- Nurse’s legal and ethical responsibility
- FDA coordinates reporting at a federal level
- Facilities have policies/procedures to report medication errors
- Documentation should be factual
- Include specific intervention implemented to protect patient safety
- Failure to document could be interpreted as negligence
- Record all names of individuals notified of error
9
Q
Reporting Medication Errors - Documents
A
- Medication administration record (eMAR) should contain information on given or omitted medications
- Written occurrence report must be completed
- Verifies patient’s safety was protected
- Identifies factors contributing to error
- Occurrence report not included in patient’s health record
- Accurate documentation is essential for legal reasons
10
Q
MedWatch
A
- The FDA Safety Information and Adverse Event Reporting Program
- Prescriptions, OTC, medical devices, biologics, herbal products, etc.
- May be reported anonymously
11
Q
NCC MERP
A
- ISMP and US Pharmacopeial Convention (USPC)
- Voluntary for consumers and healthcare providers
- Shared with FDA
12
Q
MEDMAX
A
- USPC
- National online database that hospitals and healthcare systems use to track adverse events and medication errors
- Agencies participate in MEDMAX voluntarily and subscribe to it on an annual basis
- QI tool
13
Q
Medical Error Documentation
A
- All facilities will have policies and procedures
- Done in a factual manner to include specific nursing interventions that were implemented
- Failure to document is seen as negligence or failure to acknowledge that the incident occurred
- The patient’s Medication Administration Record (MAR) - what medication was given or omitted
- The nurse who observed or made a medication error should complete a written occurrence report
- Occurrence report - allows the nurse the opportunity to provide details on what factors lead to the medication error
14
Q
Reducing Medication Errors - Follow Nursing Process
A
- Keep to the 4 steps of the nursing process:
- Assessment
- Obtain a thorough medication history
- Food and medication errors
- OT and herbal medications
- Asses renal and hepatic functions
- Determine if any body system is empaired
- Planning
- Avoid using abbreviations that could be misread
- Question unclear orders
- Do not accept verbal orders
- Implementation
- Focus entirely on the task
- Get a positive identification of patient
- Use the correct procedures and techniques for all routes of administration
- Use sterile procedures and techniques
- Calculate dose correctly
- Record medication and dose in MAR immediately after
- Evaluation
- Assess for expected therapeutic outcomes or adverse events
- Antibodies have the highest rate of drug allergy
- Assessment
15
Q
Reducing Medication Errors: Medication Reconciliation
A
- Medication reconciliation - process of comparing the medications a patient is taking with newly ordered medications
- Comparison addresses duplications, omissions, and interactions
- Should occur whenever there is a change in the site of patient care: admission to, transfers. dischage
