Medication Errors Flashcards
Medication errors
Landmark study by Institute of Medicine (IOM) in 1999
Follow-up study in 2010 showed no significant change in rates of preventable errors since the IOM study.
Just Culture
Recognizes that systems are generally at fault when error occurs
—Need for accountability
—Remediation of:
*Workplace culture
*Reporting structure
*Management behaviour
When professionals do not follow policies or have repeated errors
—Need for accountability
Remedial education
Adverse Drug Event
General term
—Encompasses all types of clinical problems resulting from medication use
Medication errors
Adverse drug reactions (ADRs)
—Allergic reaction
—Idiosyncratic reaction
Medication Errors
Preventable
Common cause of adverse health care outcomes
Drugs commonly involved in severe medication errors:
—central nervous system drugs
—anticoagulants,
—chemotherapeutic drugs
More potential for harm with “high-alert” medications
SALAD (sound-alike, look-alike drugs)
LASA (look-alike, sound-alike)
TALLman lettering
Issues Contributing to Errors
Errors can occur during any step of medication process
Procuring
Prescribing
Transcribing
Dispensing
Administering
Monitoring
Organizational issues
Educational system issues
Sociological factors
Use of abbreviations
Types of Medication Errors
Near miss
No harm event
Medication Error
Critical Incident
Near miss
Did not reach the patient
Results in no harm
No harm event
Reaches patient
Results in no harm
Medication Error
Causes harm
Critical Incident
Results in serious harm
Preventing Medication Errors
Multiple systems of checks and balances should be implemented to prevent medication errors.
Prescribers must write legible orders that contain correct information, or orders should be entered electronically.
Authoritative resources such as pharmacists or current (within the past 3 to 5 years) drug references or literature must be consulted.
Nurses need to always check the medication order three times before giving the drug.
Faculty members should not be the student’s research source regarding medications.
The rights of medication administration should be used consistently.
Preventing Medication Errors
Assessment
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.
Avoid abbreviations.
Never assume anything about items not specified in a drug order (e.g., route).
Do not hesitate to question a medication order for any reason when in doubt.
Do not try to decipher illegibly written orders; contact the prescriber for clarification.
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.
—The .25 mg may be misread as 25 mg.
—-The “.25” is sometimes called a “naked decimal”
Take time to learn special administration techniques of certain dosage forms.
Always verify new medication administration records.
Always listen to and honour any concerns expressed by patients regarding medications.
Check patient allergies and identification.
Provide a translator for patients who do not speak English
Ensure readability of labels
Use “tall-man lettering” to differentiate look-alike drug names
Responding to, Reporting, and Documenting Medication Errors
Professional responsibility
Follow facility policy.
Follow-up procedures or tests
Nurses highest priority is patient’s physiological status and safety.
Complete all necessary forms.
Document with factual information; accurate, thorough, and objective.
Avoid using judgemental words (e.g., error).
Note observed changes in patient’s physical or mental status.
Document that the prescriber was notified and any follow-up actions or orders that were implemented
Ongoing patient monitoring
The Institute for Safe Medication Practices Canada
Medication Reconciliation
Continuous assessment and updating of patient medication information
–Verification: collection of meds currently used
–Clarification: professional review of this information to ensure that all meds and dosage are appropriate
–Reconciliation: further investigation of any discrepancies
Process in which medications are “reconciled” should occur at:
Entry into the facility
Transfer into the facility
Into or out of the ICU
Discharge
Process of Medication Reconciliation
Patients provide a list of all the medications they are currently taking (including natural health products and over-the-counter drugs).
Prescriber then assesses the medications and decides if they are to be continued upon hospitalization.
Designed to ensure that there are no discrepancies between what the patient was taking at home and in hospital
Medication Reconciliation
Should be done at each stage of health care delivery:
Admission
Status change (e.g., from critical to stable)
Patient transfer within or between facilities or provider teams
Discharge (the latest medication list should be provided to the patient to take to the next health care provider)
Ethical Issues
Notification of patients
Possible consequences for nurses
Preventing Pediatric Medication Errors
Know the child’s weight and double check all calculations. Many require independent double checks
Report all medication errors.
Know the drug thoroughly.
Follow the Ten Rights of medication administration.
Avoid verbal orders in general.
Avoid distractions.
Communicate with everyone (parent/caregiver) involved in patient care.
adverse drug event
adverse drug reaction
allergic reaction
idiosyncratic reaction
undesirable occurrence concerning admin of or failure to administer prescribed medication
unexpected, unintended, or excessive responses to medication given at therapeutic dosages
immunological hypersensitivity reaction
abnormal and unexpected response to a medication
how to reduce MEs
high alert meds
med rec
double-check drugs that sound alike and look alike names
if a pt expresses concern about a drug, stop, listen, and investigate
once the student has commited an ME, the responsibility is to the pt and to be honest and accountable
insulin, opiates, anticoagulats, inj potassium
do you have a list of all the meds, including OTC you are currently taking
