Medication errors


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Medication errors

  1. 1. Medication Errors Improving Practices and Patient Safety
  2. 2. Medication Error A preventable event that leads to inappropriate medication use or patient harm.
  3. 3. Causes of Medication Errors <ul><li>NOT the result of poor-quality staff! </li></ul><ul><li>Error-prone processes involved in the medication use system contribute to medication errors </li></ul><ul><li>Excellent, experienced practitioners make mistakes </li></ul>
  4. 4. Medication Errors <ul><li>Most medication errors do not result in patient harm </li></ul><ul><li>Some medication errors result in catastrophic harm or death </li></ul><ul><li>High risk with High Alert Drugs — highly toxic drugs or drugs with a narrow therapeutic range have a high risk of causing devastating injury or death; see Davis’s Drug Guide for Nurses for a list of high alert drugs </li></ul>
  5. 5. Selected Elements of the Medication Use System <ul><li>Communication </li></ul><ul><li>Labeling, packaging, and naming </li></ul><ul><li>Administering medications (dose calculation, timing, programming of infusion devices, etc.) </li></ul><ul><li>Monitoring drug levels and therapeutic or nontherapeutic responses </li></ul><ul><li>Thorough patient education </li></ul>
  6. 6. Communication Problems <ul><li>Similar-sounding or similar-looking names </li></ul><ul><li>Using package units like “one tablet” instead of specific milligram dosage </li></ul><ul><li>Writing ambiguous or incomplete orders </li></ul><ul><li>Using abbreviations or unnecessary zeroes in an order </li></ul>
  7. 7. Misuse of Zeroes: “Lead Don’t Trail” <ul><li>Failing to use a leading zero: writing .2 mcg instead of 0.2 mcg </li></ul><ul><li>Using an unnecessary trailing zero: 1.0 mg instead of 1 mg </li></ul><ul><li>Can result in over- or under-dosing by a factor of 10 </li></ul>
  8. 8. Error-Prone Abbreviations <ul><li>Abbreviations can be misinterpreted </li></ul><ul><ul><li>Does MS mean morphine sulfate or magnesium sulfate? </li></ul></ul><ul><li>“ U” or “u” for units can look like a zero, especially if there is insufficient space between number and letter: 10u hand or computer-entered can look like 100 </li></ul><ul><li>See Davis’s Drug Guide for Nurses for a table of error-prone abbreviations and safer alternatives </li></ul>
  9. 9. Poorly Written Orders <ul><li>Quickly, sloppily written orders historically have been a source of medication errors </li></ul><ul><li>Even orders viewed on a computer screen or printed out can be misread </li></ul><ul><li>Some orders lack important elements </li></ul><ul><li>If you have to ask yourself what the order means, ask the original prescriber, too! </li></ul>
  10. 10. Sound-Alike, Look-Alike Drugs <ul><li>Some drugs sound confusingly similar or look very similar when printed or written </li></ul><ul><li>Amrinone, a cardiac inotropic agent, was renamed inamrinone because of persistent confusion with amiodarone </li></ul><ul><li>Avoid phone orders! </li></ul>
  11. 11. Labeling and Packaging Problems <ul><li>Packaging of drug products can look similar; the wrong product could be picked up inadvertently </li></ul><ul><li>TALL MAN lettering helps prevent such confusion by highlighting certain syllables for especially problematic drug pairs </li></ul><ul><ul><li>Example: acetoHEXAMIDE and acetoZOLAMIDE </li></ul></ul><ul><li>See Davis’s Drug Guide for Nurses for a list of drugs requiring Tall Man lettering </li></ul>
  12. 12. Dose Miscalculations <ul><li>Major cause of medication errors </li></ul><ul><li>Can be a mathematical error or a failure to consider patient’s age; renal or hepatic function; or other modifying factor </li></ul><ul><li>Includes miscalculation of dosage or rate of administration and misprogramming of infusion pumps </li></ul>
  13. 13. Incorrect Drug Administration <ul><li>Don’t forget the 5 Rights </li></ul><ul><ul><ul><li>Right drug </li></ul></ul></ul><ul><ul><ul><li>Right patient </li></ul></ul></ul><ul><ul><ul><li>Right dose </li></ul></ul></ul><ul><ul><ul><li>Right route </li></ul></ul></ul><ul><ul><ul><li>Right time </li></ul></ul></ul>
  14. 14. Human and Environmental Factors That Influence Errors <ul><li>Distractions </li></ul><ul><li>Poor staffing </li></ul><ul><li>Culture of perfection </li></ul><ul><li>Questioning physicians is tacitly discouraged </li></ul><ul><li>Punitive response to error (“shame and blame”) </li></ul>
  15. 15. Prevention Strategies for Nurses <ul><li>Clarify any order that is not obviously and clearly legible </li></ul><ul><li>Do not accept orders with the abbreviation “u,” “U,” or “IU” for units </li></ul><ul><li>Clarify abbreviated drug names or dosing frequencies </li></ul>
  16. 16. Prevention Strategies for Nurses (Cont’d) <ul><li>If dose requires >3 or <1/2 of a dosing unit (e.g., ampoules or tablet), have another healthcare provider check the original order and recalculate dose </li></ul><ul><li>ALWAYS confirm unusual dosages with the provider </li></ul><ul><li>Refer to a third source, such as your Davis’s Drug Guide or a pharmacist </li></ul>
  17. 17. Prevention Strategies for Nurses (Cont’d) <ul><li>Clarify any order that does not include metric weight (mg, mcg, gram, etc.), dosing frequency, or route of administration </li></ul><ul><li>Orders should include the indication — clarify with prescriber </li></ul><ul><li>If the facility uses handwritten systems, check the nurse's/clerk's transcription against the original order; make sure stray marks or initials do not obscure the original order </li></ul>
  18. 18. Prevention Strategies for Nurses (Cont’d) <ul><li>Do not start a patient on a new medication by borrowing medications from another patient </li></ul><ul><li>Doing so bypasses the double check provided by the pharmacist’s review of the order </li></ul>
  19. 19. Prevention Strategies for Nurses (Cont’d) <ul><li>Always check the patient's name band/bar code before administering medications </li></ul><ul><li>Verbally addressing a patient by name does not provide sufficient identification </li></ul><ul><li>Always check for allergies </li></ul><ul><li>Consider drug/food interactions and educate patient </li></ul>
  20. 20. Prevention Strategies for Nurses (Cont’d) <ul><li>Be sure to fully understand any drug administration device before using it </li></ul><ul><li>This includes infusion pumps, inhalers, and transdermal patches </li></ul><ul><li>Have a second practitioner independently check original order, dosage calculations, and infusion pump settings for high alert medications </li></ul>
  21. 21. Preventing Med Errors in the Home <ul><li>Medication errors occur in the home, too; educate patients about safe medication use </li></ul><ul><li>Important elements include </li></ul><ul><ul><li>Generic and brand name of drug </li></ul></ul><ul><ul><li>Purpose of drug </li></ul></ul><ul><ul><li>Dosage and how to self-administer drug </li></ul></ul><ul><ul><li>Minor and serious side effects and what to do if they occur </li></ul></ul><ul><ul><li>Follow-up care, including drug-level monitoring </li></ul></ul><ul><li>See Davis’s Drug Guide for Nurses for more information about patient education </li></ul>
  22. 22. Reporting Medication Errors <ul><li>Making an error does not make you a bad nurse; excellent practitioners, pharmacists, physicians, and nurses make mistakes </li></ul><ul><li>Data about med errors will help initiate better prevention strategies </li></ul><ul><li>Report errors online </li></ul><ul><li>Or by phone: 1-800-FDA-1088 </li></ul>