RAHIMA M . SALENDAB NQMC,MGH, MADINA
Causes for errors:Too many telephone callsOverload/ week endsToo many PatientsLack of concentrationNo one available t...
ADVERSE DRUG EVENT                :Any injury caused by the use (or non use) of a drug.            AN ERROR OF COMMISSION:...
An error of omission          occurs whenthe administration process is not completed      for example: not administering a...
TYPE OF MEDICATION ERROR1. PRESCRIBING ERRORS .2. OMISSION ERRORS.3. WRONG TIME ERRORS.4. UNAUTHORIZED DRUG ERRORS.5. IMPR...
 Occurs when prescriber orders drug for specific patientdrugdosedosage formroute of administrationlength of therapy...
 Failure to administer an ordered dose  (not late dose). Omitted dose is not an error when:  cannot take anything by mo...
 Standardized administration times Acceptable interval surrounding  scheduled time. Occasionally unavoidable:  patient...
 Administration of medication to patient  without proper authorization by  prescriber. Medication for patient given to a...
 Dose that is greater or less than prescribed  dose. Can occur when additional dose is  administered      Delay in docu...
   Doses administered as different    form than ordered.
   Using bacterio static saline instead of    sterile water to reconstitute lyophilized    powder for injection.
 Examples:  Subcutaneous injection that is giventoo deep  Intravenous (IV) drug is allowed to  infuse via gravity inste...
 Monitoring expiration dates is very  important. Refrigerated drugs stored at room  temperature may decompose & lose  ef...
 Inadequate drug therapy review. Examples:  Ordering serum drug levels but not  reviewing them.   Not ordering drug le...
 Failure to adhere to prescribed drug  regimen.Example:Patient does not complete antibiotics   therapy-saves a few doses.
 Errors that cannot be placed into  category.Examples:   Medication dispensed without   adequate patient education.
 1. Human factors. 2. Systems. 3. Abbreviations. 4. Oral orders. 5. Look-alike and sound-alike drugs. 6. Dosage calc...
Abbreviation               Intended                Misinterpretation> and <                   Greater than Less than   Oft...
Types of Verbal Order ErrorsWrong DrugClonidine misheard as KlonopinAmiodarone misheard as amrinoneWrong Dose15 mg mi...
NURSING RESPONSIBILITIESOnly administer meds you have prepared.Know the purpose and expected outcomes.Do not leave meds...
STANDARD PRECAUTIONWash hands before beginning medicationWear gloves for parenteral injectionsWear gloves if helping pu...
LOOK ALIKE MEDICINE
SAMPLE OF ILLEGIBLE HAND WRITING
7 RIGHTS OF MEDICATION       ADMINISTRATION RIGHTPATIENTRIGHT DRUGRIGHT DOSERIGHT ROUTERIGHT TIMERIGHT FREQUENCYRIG...
SOUND ALIKEFolinic Acid          Folic AcidAmidaron               Amlor  Zinnat               Zantac  Concor              ...
HOW TO PREVENT MEDICATION         ERROR?????When your doctor gives you a prescription, ask him or her totell you the name ...
NO ONE CAN     MOTIVATE….          Just because you cannot                                do it TODAYIF YOU ARE NOT WILLIN...
Medication error
Medication error
Medication error
Medication error
Medication error
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Medication error

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Lecture By Sr.Rahima M salendab
NQMC,,MGH Madina

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Transcript of "Medication error"

  1. 1. RAHIMA M . SALENDAB NQMC,MGH, MADINA
  2. 2. Causes for errors:Too many telephone callsOverload/ week endsToo many PatientsLack of concentrationNo one available to double checkStaff shortageSimilar drug namesNo time to counselIllegible prescriptionMisinterpreted prescription
  3. 3. ADVERSE DRUG EVENT :Any injury caused by the use (or non use) of a drug. AN ERROR OF COMMISSION:Is something that happen from administration of the medication for example : giving the wrong medication
  4. 4. An error of omission occurs whenthe administration process is not completed for example: not administering an ordered medication.
  5. 5. TYPE OF MEDICATION ERROR1. PRESCRIBING ERRORS .2. OMISSION ERRORS.3. WRONG TIME ERRORS.4. UNAUTHORIZED DRUG ERRORS.5. IMPROPER DRUG ERRORS .6. WRONG DOSE FORM ERRORS.7. WRONG DOSE PREPARATION ERRORS.8. WRONG ADMINISTRATION TECHNIQUE ERRORS .9. DETERIORATED DRUG ERRORS .10.MONITORING ERRORS .11.COMPLIANCE ERRORS .
  6. 6.  Occurs when prescriber orders drug for specific patientdrugdosedosage formroute of administrationlength of therapynumber of dosesadministrationdrug concentrationinadequate or incorrect instructions for useillegible handwriting
  7. 7.  Failure to administer an ordered dose (not late dose). Omitted dose is not an error when: cannot take anything by mouth (NPO). providers are waiting for drug level results. patient refuses.
  8. 8.  Standardized administration times Acceptable interval surrounding scheduled time. Occasionally unavoidable: patient is away care area for test. medication is not available at time it is due.
  9. 9.  Administration of medication to patient without proper authorization by prescriber. Medication for patient given to another patient. Nurse gives medication without prescriber order. Patients “share” prescriptions.
  10. 10.  Dose that is greater or less than prescribed dose. Can occur when additional dose is administered Delay in documenting dose Absence of documentation Inaccurate measurement of oral liquid Exclusions from this error type
  11. 11.  Doses administered as different form than ordered.
  12. 12.  Using bacterio static saline instead of sterile water to reconstitute lyophilized powder for injection.
  13. 13.  Examples: Subcutaneous injection that is giventoo deep Intravenous (IV) drug is allowed to infuse via gravity instead of using an IV pump. Instilling eye drops in wrong eye.
  14. 14.  Monitoring expiration dates is very important. Refrigerated drugs stored at room temperature may decompose & lose efficacy.
  15. 15.  Inadequate drug therapy review. Examples: Ordering serum drug levels but not reviewing them.  Not ordering drug levels when required.  Prescribing antihypertensive agent & then failing to check blood pressure.
  16. 16.  Failure to adhere to prescribed drug regimen.Example:Patient does not complete antibiotics therapy-saves a few doses.
  17. 17.  Errors that cannot be placed into category.Examples:  Medication dispensed without adequate patient education.
  18. 18.  1. Human factors. 2. Systems. 3. Abbreviations. 4. Oral orders. 5. Look-alike and sound-alike drugs. 6. Dosage calculation. 7. At-risk drugs
  19. 19. Abbreviation Intended Misinterpretation> and < Greater than Less than Often used the OppositeΜg Microgram Mistaken as mgIU international Unit Mistaken as IVqd, QD or QOD Every day or every Often confused for other day each othercc cubic centimeter Misread as ‘u’Zero after decimal(1.0) 1 mg Misread as 10 mgZero not written before Half mg (0.5) Misread as 5 mgdecimal (.5mg)
  20. 20. Types of Verbal Order ErrorsWrong DrugClonidine misheard as KlonopinAmiodarone misheard as amrinoneWrong Dose15 mg misheard as 50 mg2 mg misheard as 20 mgWrong LabsBlood glucose misheard as 257 instead of 157 patient received 6 units of insulin instead of 2.
  21. 21. NURSING RESPONSIBILITIESOnly administer meds you have prepared.Know the purpose and expected outcomes.Do not leave meds at bedside.Check ID band before administering.Some meds need checking by another nurse.Consult with supervisor or Dr if dosage is outside ofrecommended range .Do not administer medications calculated by someoneelse except pharmacist .
  22. 22. STANDARD PRECAUTIONWash hands before beginning medicationWear gloves for parenteral injectionsWear gloves if helping put pills in mouth
  23. 23. LOOK ALIKE MEDICINE
  24. 24. SAMPLE OF ILLEGIBLE HAND WRITING
  25. 25. 7 RIGHTS OF MEDICATION ADMINISTRATION RIGHTPATIENTRIGHT DRUGRIGHT DOSERIGHT ROUTERIGHT TIMERIGHT FREQUENCYRIGHT DOCUMENTATION
  26. 26. SOUND ALIKEFolinic Acid Folic AcidAmidaron Amlor Zinnat Zantac Concor Zocor Tazocin Prazocin Kafocid Keflex Lasix LosecAldactone AldometRanitidine Loratidine voltarin ventolin
  27. 27. HOW TO PREVENT MEDICATION ERROR?????When your doctor gives you a prescription, ask him or her totell you the name of the drug, the correct dosage, and whatthe drug is used for. Be sure you understand the directions forany medications you may be taking including the correctdosage, storage requirements, and any special instructions.Finally, never be hesitate to ask questions. If the name of thedrug on your prescription looks different than you expected, ifthe directions appear different than you thought, or if the pillsor medication itself looks different, tell your doctoror Pharmacist right away. Asking questions if you have anysuspicions at all is a free and easy way to ensure that youdont become the victim of a medication error.
  28. 28. NO ONE CAN MOTIVATE…. Just because you cannot do it TODAYIF YOU ARE NOT WILLING TO DO YOUR SELF… Does NOT mean you will not do it SOMEDAY If you are not willing to learn, No one can help you. If you are determined to learn, No one can stop you …!!

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