Medication Errors: Submitting Error Forms Flashcards
Patient ID Example?
11111 or N/A
Patient Age Example?
68 (just number in years)
Patient Gender Example?
Male or Female
Patient weight in kg Example?
70 (2.2 kg in 1 lb)
Patient Error Category Example?
Category A - No error but circumstances could have lead to an error
Category B-D - Error occurred but no harm (patient may or may not have received medication)
Category E-H - Error occurred and caused harm
Category I - Error occurred and patient died
Patient Error Category Example?
Category A - No error but circumstances could have lead to an error
Category B-D - Error occurred but no harm (patient may or may not have received medication)
Category E-H - Error occurred and caused harm
Category I - Error occurred and patient died
Patient Event Date Example?
4/1/15
Event Time Example?
9:00 AM
Setting of initial error example?
?
Personnel Involved example?
Nurse
Drug strength example?
100 units/mL
Frequency example?
Continuous infusion
Route of administration example?
IV
Status example?
Legend
Dosage form example?
IV
Packaging example?
IV Solution
Error Type example?
Improper dose error, monitoring error
Cause of Error example?
Human Factors: Knowledge Deficit
Contributing Factors example?
Lack of proper trraining
Contributing Factors example?
Lack of proper training
Description of event example?
This 68 year old man was to be receiving a heparin infusion for his NSTEMI. The nurse was monitori9ng the heparin drip, according to the protocol and drew the 6 hours aPTT/heparin correlation. She also drew the PT/INR, which typically used to monitor warfarin. Because the aPTT/heparin correlation was taking a while to come back, she adjusted the heparin drip based on the INR. She gave a 2000 unit bolus and increased the drip rate by 100 units per hour. At 2 pm, when she repeated the level, it was greater than 2.2 and she also noticed that the previous level she was waiting on came back at 1.8. One hour later, the patient was unresponsive and a head CT showed a massive hemorrhagic stroke. He was then transferred to the NICU. To avoid errors such as this in the future, in-service education could be provided to emphasize the appropriate lab monitoring for each medication. Additionally, the hospital policy could be adjusted so two providers must sign off (another nurse or the physician) prior to making dose adjustments. I recommend an in-service be completed twice-annually to ensure the staff knows how to use the protocol. Additionally, the policy should be updated so two nurses should sign off before dosage increases. To ensure this is done properly and avoid future errors, the clinical pharmacist on service will be responsible for conducting a medication use evaluation on these heparin forms monthly.
