Medication Errors Flashcards
What constitutes a medication error?
Any PREVENTABLE event that MAY CAUSE or lead to INAPPROPRIATE MEDICATION USE OR PATIENT HARM while the medication is in the control of the health care professional, patient, or consumer. Can be related to Professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.
What are the types of medication errors?
Prescribing error, omission error, commission error, wrong time error, unauthorized drug error, improper dose error, wrong dose form, wrong drug preparation error, wrong administration technique error, deteriorated or expired drug error, monitoring error, compliance error, other medication error.
The abbreviation for Units is?
U - commonly mistaken for zero; four; cc
What methods can be used to reduce medication errors?
5 rights (right patient, right medication, right does, right time, right route), system of checks and balances
What are the causes of medication errors?
Problems with labels or in drug packaging, LOOK-ALIKE OR SOUND-ALIKE NAMES, use of lettered or numbered prefixes and suffixes in drug names, equipment failure or malfunction, ILLEGIBLE HANDWRITING, improper transcription, INACCURATE DOSAGE CALUCULATION, INADEQUATELY TRAINED PERSONNEL.
Inappropriate ABBREVIATIONS used in prescribing, labeling errors, EXCESSIVE WORKLOAD, lapses in individual performance, medication unavailable.
The abbreviation for Micrograms is?
(μ g) commonly mistaken for milligrams
The abbreviation for every day is?
Q.D. commonly mistaken for QID(four times daily)
The abbreviation for every other day is?
Q.O.D commonly mistaken for QD(daily) and QID(four times daily)
The abbreviation for subcutaneous is?
SC or SQ commonly mistaken for SL(sublingual)
The abbreviation for three times a week is?
TIW commonly mistaken for TID(three times a day) or twice a week
The abbreviation for discharge or discontinue is?
D/C commonly mistaken prematurely discontinued medications
The abbreviation for half strength is?
HS commonly mistaken for HS (hour of sleep)
The abbreviation for cubic centimeters is?
cc commonly mistaken for U(units)
The abbreviation for ears, both left and right, is?
AU, AS, AD commonly mistaken for OU (both eyes), OS (left eye), and OD (right eye)
The abbreviation for international unit is?
IU commonly mistaken for IV(intravenous); 10(ten)
The abbreviation for Morphine sulfate is?
MS commonly mistaken for magnesium sulfate (MS04 and MgSO4)
Can error-prone abbreviations be used in print?
NOOOO!!! It may still be confused and may be copied into written orders. It also perpetuates the impression that they are acceptable.
What are the 5 rights of medication administration?
Right patient Right medication Right dose Right time Right route
How can a system of checks and balances be instituted?
Patient medication counseling
Reduced environmental barriers-workload, clutter, etc.
Separate look-alike, sound-alike drugs
Read the label 3 times (R3)
Use of electronic prescriptions/CPOE (computerized physician order entry)
Do not use single use dosage forms on multiple patients
Tall Man lettering for look-alike names
What are the high-alert medications?
Parenteral chemotherapy IV insulin potassium chloride for injection concentrate IV unfractionated heparin epidural//intrathecal drugs neuromuscular blocking agents potassium phosphates injection methotrexate warfarin narcotics
Where do you report a medication error?
ISMP, FDA, Medical Event Reporting System for Transfusion Medicine (MERS-TM), MERP, The Joint Commission, USP’s MEDMARX Reporting System.
Health care organizations should….
encourage thorough reporting of errors & near misses, develop systems & procedures to collect information, and analyze medications errors
What are the barriers to not reporting?
blame for negative outcome, being considered incompetent, reprimand from supervisor, “telling” on someone else, patients developing negative attitudes, lawsuits, reporting that is not anonymous, displeasure with extra work to complete reporting, too busy to report, forget to report, disagreement on organization’s definition of an error.
What information should be toted when reporting errors?
Patient Info (age, gender, weight), Event information (date of error, weekend, holiday, time, setting/location), Description of Event (free text, narrative entry, error perpetuation, error discovery, other relevant information), Patient outcome (select error category), Product Information (Name, strength, dose frequency, route, status, manufacturer, dosage form, packaging), Personnel involved, Type of error, Cause, Contributing factors (systems related).
What categories are used for NCC MERP when no error occurs?
Category A - circumstances or events that have the capacity to cause error
What categories are used for NCC MERP when an error but no harm occurs?
Category B, C, and D.
What categories are used for NCC MERP when an error and harm occurs?
Category E, F, G, and H.
What categories are used for NCC MERP when an error and death occurs?
Category I
How can we develop a system and policies that will prevent errors?
Work with the medication safety team to develop a fail-safe for the future, advocate for error/near-miss reporting, practice safe-medicine through appropriate abbreviations, precautions, checks and balances.
