Medication Safety and Error Reduction Flashcards
Put in order
- Documentation
- Medication Administration and the Nursing Process
- Prescriptions/Medication Orders
- Prescriptions/Medication Orders
- Medication Administration and the Nursing Process
- Documentation
Only indicated for emergencies
- Routine/Standing Order Prescriptions
- Single/One-Time Prescriptions
- STAT prescriptions
- PRN Prescriptions
- Verbal Orders
- Telephone Orders
- Written Order
• Verbal Orders
• If receiving ? order, “have second nurse listen”, READ BACK ORDER
- Routine/Standing Order Prescriptions
- Single/One-Time Prescriptions
- STAT prescriptions
- PRN Prescriptions
- Verbal Orders
- Telephone Orders
- Written Order
• Telephone Orders
Nursing students cannot accept ? or ? orders
- Routine/Standing Order Prescriptions
- Single/One-Time Prescriptions
- STAT prescriptions
- PRN Prescriptions
- Verbal Orders
- Telephone Orders
- Written Order
- Telephone Orders
* Verbal Orders
Prescriptions or Medication Orders
KEY ELEMENTS?
a. Patient Name + Second Identifier (DOB, or Medical Record #)
b. Date the drug order was written
c. Name of Drug
d. Drug Dosage Amount
e. Drug Dosage Frequency
f. Route of Administration
g. Prescribers Signature
h. None
i. All
i. All
Read the Does for Documentations
Do check to be sure you have the correct medical record before documenting.
• Do include the time you gave a medication, the route of administration, and the patient’s response.
• Do document:
• Only the facts
• Patient teaching
• Any precautions and/or preventative measures
• The exact time, message, response when communicating with a physician and/or health care provider
• A patient’s refusal to take a medication or allow a treatment and appropriate nursing interventions and report to the patient’s
physician and the charge nurse.
• Do record each phone call to a physician with exact time, message, and response.
• Do give precise descriptions.
• Do document patient care at the time you provide it.
Ok
Read the DON’TS OF DOCUMENTATION
• Don’t document a symptom, such as “c/o pain,” without noting what you did to intervene on the
patient’s behalf.
• Don’t alter a patient’s medical record and/or nursing notes.
• Don’t give excuses, such as “medication not given because not available.”
• Don’t document ahead of time.
• Don’t mention the term incident report in documentation. Incident reports are confidential and filed
separately. Document only the facts of the medication error or incident and appropriate actions taken.
• Don’t use the following terms: by mistake, by accident, accidentally, unintentional, or miscalculated.
• Don’t record casual conversations with peers, prescribers, or other members of the health care team.
• Don’t use abbreviations. Some agencies or facilities may still keep a list of approved abbreviations, but
overall their use is discouraged.
• Don’t use negative language.
ok
Read the does and don’ts of an INCIDENT REPORT
• Report all errors, and implement corrective measures immediately. Complete an incident report within
the time frame the facility specifies, usually 24 hr.
• Report includes: Client’s identification Name and dose of the medication Time and place of the incident
Accurate and objective account of the event Who you notified, What actions you took, Your signature
(or that of the person who completed the report)
• Don’t mention the term incident report in documentation. Incident reports are confidential and filed
separately. Document only the facts of the medication error or incident and appropriate actions taken
ok
- Nurses compile a list of each client’s current medications
- Prescription, Over The Counter, Herbals, ALL OF IT. Names, dosages, frequency
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
MEDICATION RECONCILIATION
- Important to compare this list with all new medication prescriptions during phases of care:
- Admission to Hospital
- Transfer between units/facilities
- Discharge
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
MEDICATION RECONCILIATION
• Ask patient to keep a medication list, have patient bring in medication bottles, call home pharmacy
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
MEDICATION RECONCILIATION
▪Filing an Incident Report is one of the best things you can do to prevent future
harm to patients
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
REPORT MEDICATION ERRORS
▪ Report actual events, near misses, potential ways to harm a patient
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
REPORT MEDICATION ERRORS
▪ Incident Reports allow review of the ?
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
SWISS CHEESE MODEL
Many components in Health Care to prevent an Error
REPORT MEDICATION ERRORS, MEDICATION RECONCILIATION, SWISS CHEESE MODEL
SWISS CHEESE MODEL
