Medication errors Flashcards
Who are generally at fault when errors occur
The systems
How to prevent system flaws in med errors
Need for accountability, reexamine workplace culture, reporting structure, management behaviour
Adverse drug event
All types of clinicals problems resulting from medication including medication errors and adverse reactions
Types of adverse drug reactions (ADRs)
Allergic reaction and idiosyncratic reaction
Medication errors
is a preventable common cause of adverse health care outcomes
Which type of drug has more potential for harm
High alert medications
Which step of medication administration can errors occur
Any step
Procuring
Prescribing
Transcribing
Dispensing
Administering
Monitoring
Issues contributing to errors
Organizational issues
Educational system issues
Sociological factors
Use of abbreviations
Types of medication
SALAD: sound alike, look alike drugs
LASA: look alike sound alike
Near miss
No harm event
Medication error
Critical incident
Near miss
Did not reach the patient and results in no harm
No harm event
Reaches patient but results in no harm
Medication error
Reaches patent and causes harm
Critical incident
Results in serious harm
Preventing medications errors
- Having multiple checks and balances
- Prescribes must write legible orders that are correct info entered in electronically
- Use resources (pharmacists or drug references)
- three checks
- ten rights
- do not use others people words as student resources
type of orders to minimize
Verbal or telephone orders
How to give a telephone/verbal order
Repeat order to prescribers, spell drug aloud, speak slow and clearly, have the indication next order
What to do if written orders are illegible
contact prescriber
Should you use trailing zeros
no
Should you have leading zeros for decimal dosage
yes
What to do if patients do not speak english
Provide a translator
When to use tall man lettering
When look alike drug names come
How to respond/report/document to a med error
Follow facility policy,
follow up procedures/tests
complete all necessary forms,
avoid using judgemental words,
take responsibility,
nurse with the highest priority is patient’s physiological status and safety,
document that the prescriber was notified and any follow up action or orders that were implemented
The Institute for Safe Medication Practices Canada
Ensuring Accuracy in Patient Medication Information through
Continuous assessment and updating patient medication info
- Verification
- Clarification
- Reconciliation
where should medication reconciliation occur
Entry into the facility
Transfer into the facility
Into or out of the ICU
Discharge
Why do prescribers assess medications upon hospitalization
To ensure there are no discrepancies between what the patient was taking at home and hospital
At what level should reconciliation be done
At every level
- Admission
- Status change
- Patient transferred between facilities/teams
- Dishcharge
Preventing peds medication errors
- Know the weight and double check med calc
- communicate with everyone (parent/caregiver)
