Chapter 7: Medication Errors and Risk Reduction Flashcards
Healthcare Provider Factors Contributing to Medication Errors
-omitting one of the rights of drug administration
-failing to perform agency system checks (pharmacy)
-not taking patient variables into consideration (age, body, renal and hepatic function, lab tests)
-administering medication from verbal or phone orders; from illegible or incomplete orders
-practicing under stressful conditions
Severity of medication error
sentinel or near sentinel event is reported to federal government agencies
some medication errors will stay at the institution depending on the severity of the event
all medication errors are monitored by the quality assurance risk management departments
Patient/Caregiver Factors Contributing to Medication Errors
-not informing healthcare providers all the medications they are taking
-not following instructions
-filling prescriptions at multiple pharmacies
-taking prescriptions from various providers
-taking someone else’s prescription
-taking leftover medication from previous illness,
not filling/refilling prescriptions
Strategies nurse can implement to reduce medication errors and incidents
Assessment: ask about food or drug allergies, are they taking their current medication as prescribed, taking any OTC or herbal supplements, how are their renal or hepatic function as well as other body systems that can affect pharmacotherapy
Planning:
Implementation
Evaluation:
Strategies nurse can implement to reduce medication errors and incidents
Assessment: ask about food or drug allergies, are they taking their current medication as prescribed, taking any OTC or herbal supplements, how are their renal or hepatic function as well as other body systems that can affect pharmacotherapy
Planning: avoid using abbreviations that can be misunderstood, question unclear orders, follow facilities procedures and policies; ask patient for understanding of goals of drug therapy
Implementation: eliminate potential distractions; follow the rights of administration and checks; always document right after administration; make sure patient does not crush extended release tablets or capsules; be aware of name lookalikes
Evaluation: assess patient for therapeutic outcomes and determine if adverse reactions occurred
MedWatch
Under FDA
platform for health care providers and public to report
provides up to date clinical information
NURSE’S ETHICAL AND LEGAL RESPONSIBILITY TO REPORT MEDICATION ERRORS
Documentation in Patient’s Medical Record vs Reporting Error
Patient Medical record: documents specific nursing interventions implemented to protect patient safety (vital signs, monitoring adverse effects), document all people informed of error
Reporting error: written document of error and the nursing interventions done; NOT INCLUDED IN PATIENT RECORD
Sentinel Events
unexpected occurrences that lead to death or serious physical or psychological injury; ALWAYS INVESTIGATED
Root Cause Analysis
seeks to prevent another occurrence from happening by understanding what happened, why, and what can be done to prevent it from happening again
Medication Reconciliation
process of tracking patient’s medications as they proceed from one health care provider to another; especially for older patients who are receiving multiple prescription; prevents medication error, should be done upon admission and discharge
Patient Education
know all about the drug (name, dose, use, route, SE) what side effects to report ASAP, read drug label before taking, carry a list of all OTC and herbal supplements, use appropriate administration devices for medication, ask questions
Methods to Reduce Number of Medication Errors
1) EHR (electronic health records) and e prescription
2) BCMA (Barcode assisted medication administration) to help verify and document medication administration
3) risk management department to analyze risks and minimize number of medication errors (RCA)
