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They can be avoided.
Medication Errors
Objectives
• Define the following terms: medication
error, incident/occurrence, sentinel event,
and culture of safety
• Id...
Objectives
• Define the role of communication in
medication safety
• Identify state and federal agencies
responsible for m...
Definitions
• Medication Error – any preventable event
that may cause or lead to inappropriate
medication use or harm to a...
Definitions
• Culture of Safety – Culture refers to
influences and beliefs held by a group
of individuals in an organizati...
Culture of Safety
• “A safety culture reflects the shared
commitment of management and
employees toward ensuring the safet...
Common Medication Error Culprits
• Fentanyl patches can cause cross-
contamination and overdosage due to a
transdermal del...
Examples of
Common Medication Errors
• Acetaminophen: Multiple acetaminophen-containing
medications can be inadvertently c...
Examples of
Common Medication Errors
• Common over-the-counter cough and
cold products, especially in children
• Error(s):...
Examples of
Common Medication Errors
• Sustained or extended release
medications, such as Morphine SR or
Oramorph
• Error(...
Examples of
Common Medication Errors
• Methadone overdosage can occur due to
the long-acting nature of this drug and the
p...
The “Rights” of Medication Administration
The “Rights” of Medication Administration
• Right dose
• Right time
• Right route
• Right medication
• Right client
• Righ...
Triple check medication label/order before
administering:
• When removing the bottle/vial from a
cabinet, drawer or medica...
Prevention Strategies
• Client identification
• Communication
• Physician orders
• Focus on medication preparation
• Corre...
Patient Identifiers
Verify patient identity by a minimum of two identifiers:
• For the alert and oriented client:
o Ask cl...
Prescription Label Components
Top of label includes:
Dispensing pharmacy name,
address and phone number
A. Prescription ID...
Medication Orders - Communication
• Written physician orders for
medications: These should be
dispensed by a licensed phar...
Medication Orders - Communication
• Telephone orders - A licensed
registered nurse may take a
medication order:
– Directly...
Safe Medication Structure –
Communication
• SBAR is a structured
communication tool to
identify common
expectations for cr...
Communication
• Accurate, regular communication is
necessary for medication safety.
• It includes written communication,
s...
Communication
• It is vital to educate clients and their
families about their actions related to
medication, adverse effec...
Documentation
Documentation refers to:
• A method of communication necessary to
accurately represent an updated, current
v...
Documentation
Documentation is used for:
• The identification and recording of new
medications, ongoing medications,
chang...
Documentation
• Accurate documentation of
medication administration allows for a
seamless flow of providers regarding a
cr...
Tips and Strategies for Safe Medication
Administration
• Understand that medication errors are
preventable.
• Correctly id...
Tips and Strategies for Safe Medication
Administration
• Be aware of client’s medication allergy
history and be prepared t...
Tips and Strategies for Safe Medication
Administration
• Do not crush sustained or extended
release medications for oral o...
Tips and Strategies for Safe Medication
Administration
• Dispense medications from properly
labeled containers into medici...
Tips and Strategies for Safe Medication
Administration
• Remember the 6 “Rights” of medication
administration.
• Check med...
Medication Administration Scenarios
• Susan, a private duty registered nurse, has prepared
Mr. Brown’s 10 a.m. medications...
Medication Administration Scenarios
• Susan, a private duty registered nurse, has prepared
Mr. Brown’s 10 a.m. medications...
Medication Administration Scenarios
• Charlotte, a licensed practical nurse, is caring for Mrs.
Hudson in her home for the...
Medication Administration Scenarios
• Charlotte, a licensed practical nurse, is caring for Mrs.
Hudson in her home for the...
Agencies Governing
Medication Safety
• Centers for Disease Control and Prevention
(CDC):
– Promotion of safe injection pra...
Agencies Governing
Medication Safety
• Drug Enforcement Agency (DEA):
– National Drug Threat Assessment
Summary
– Registra...
Medication Errors - Causes
• “Medication errors usually occur because of
multiple, complex factors. All parts of the
healt...
References
• FDA 101: Medication Errors, Consumer Health
Information, www.fda.gov/consumer, US Food and
Drug Administratio...
References
• SBAR Communication,
info@saferhealthcare.com, 2015
• Patient Safety, Michigan Department of
Community Health,...
References
• Safety and Heath Topics - Culture of
Safety, www.osha.gov, 2011
• Institute for Safe Medication
Practices, ww...
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Medication Errors

ComForCare explains the common errors when it comes to medication.

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Medication Errors

  1. 1. They can be avoided. Medication Errors
  2. 2. Objectives • Define the following terms: medication error, incident/occurrence, sentinel event, and culture of safety • Identify five medication errors • Identify five safe practices to prevent medication errors • Identify the role of proper documentation in medication safety
  3. 3. Objectives • Define the role of communication in medication safety • Identify state and federal agencies responsible for medication safety
  4. 4. Definitions • Medication Error – any preventable event that may cause or lead to inappropriate medication use or harm to a client • Incident or Occurrence – anything outside of normal routine or unexpected; usually untoward • Sentinel Event – any adverse occurrence resulting in death or serious physical or psychological harm
  5. 5. Definitions • Culture of Safety – Culture refers to influences and beliefs held by a group of individuals in an organization; it is the background against which day-to-day work occurs. Administrative style, mission and goals are all aspects of culture. • Culture of safety reflects work in an atmosphere where safe operations on all levels are a common priority and belief.
  6. 6. Culture of Safety • “A safety culture reflects the shared commitment of management and employees toward ensuring the safety of the work environment”… • A safety culture permeates all aspects of the work environment and is reflected in a level of awareness and accountability for safety on the part of every individual in an organization.” The National Institute for Occupational Safety and Health (NIOSH), 2011
  7. 7. Common Medication Error Culprits • Fentanyl patches can cause cross- contamination and overdosage due to a transdermal delivery system for a potent, long-acting opioid. • Error(s): – Changing patch more frequently than the recommended 72 hours – Adding more patches than prescribed – Cutting patches with intent to decrease dose allowing leaking of the opioid, which can alter absorption and cause potential contamination to the skin of others that may touch the patch
  8. 8. Examples of Common Medication Errors • Acetaminophen: Multiple acetaminophen-containing medications can be inadvertently combined, causing overdose. Opioid pain relievers (Norco, Vicodin, etc.) are given in combination with over-the-counter medications containing acetaminophen (sleep aids, such as phenylepherine or Benadryl, or decongestants). • Error(s): – Increasing frequency of medication beyond recommended dosing – Combining with other acetaminophen containing medications • Result: In cumulative acetaminophen, exceeding the maximal 24 hour doses of 4 grams or more, can result in potential fatal liver toxicity and damage.
  9. 9. Examples of Common Medication Errors • Common over-the-counter cough and cold products, especially in children • Error(s): – Using kitchen utensil teaspoons/tablespoons to measure medication – Administration of combination drugs containing decongestants, such as phenylepherine, not suited in the under 12 year-old population or adults with hypertension
  10. 10. Examples of Common Medication Errors • Sustained or extended release medications, such as Morphine SR or Oramorph • Error(s): – Crushing such medications for administration through NG/PEG tubes – Mixing crushed medication with applesauce causing rapid absorption of concentrated dose designed to be time- released in the GI tract
  11. 11. Examples of Common Medication Errors • Methadone overdosage can occur due to the long-acting nature of this drug and the potential for breakthrough pain. • Error(s): – Potential miscalculations can occur, since Methadone requires complex dosing calculations for equianalgesic doses. – Misadministrations can occur due to a lack of knowledge about administration as an opioid pain reliever as opposed to a maintenance medication for substance dependence.
  12. 12. The “Rights” of Medication Administration
  13. 13. The “Rights” of Medication Administration • Right dose • Right time • Right route • Right medication • Right client • Right documentation
  14. 14. Triple check medication label/order before administering: • When removing the bottle/vial from a cabinet, drawer or medication box • Before pouring or preparing medication dose and bringing to client • After preparing dose in medicine cup or syringe The “Rights” of Medication Administration
  15. 15. Prevention Strategies • Client identification • Communication • Physician orders • Focus on medication preparation • Correct documentation
  16. 16. Patient Identifiers Verify patient identity by a minimum of two identifiers: • For the alert and oriented client: o Ask client to state name and birth date or address. o Do not allow others to answer for them. o Do not ask ‘yes/no’ questions for identification. • For the mentally/neurologically challenged client: o Spokesperson requires legal authorization, such as Durable Power of Attorney for Healthcare (DPOA) for client identification.
  17. 17. Prescription Label Components Top of label includes: Dispensing pharmacy name, address and phone number A. Prescription ID # B. Prescriber C. Date dispensed D. Client name E. Medication, dose and form F. Quantity G. Refill quantity H. Manufacturer I. Expiration Date J. Medication Instructions
  18. 18. Medication Orders - Communication • Written physician orders for medications: These should be dispensed by a licensed pharmacy with accurate, printed transcription and labeling on original medication bottle for safe identification of medication and prescription orders.
  19. 19. Medication Orders - Communication • Telephone orders - A licensed registered nurse may take a medication order: – Directly and only from a licensed physician – When there is a change in patient condition or lab value – As a part of accepted, regulated scope of practice The SBAR Communication Tool is ideally suited to format a conversation for telephone orders.
  20. 20. Safe Medication Structure – Communication • SBAR is a structured communication tool to identify common expectations for critical message delivery and reception. • It uses a standardized communication technique. • This tool was originally developed for critical communication by the US Navy on nuclear submarines.
  21. 21. Communication • Accurate, regular communication is necessary for medication safety. • It includes written communication, such as prescription labels, medication administration records and clear prescriber orders. • By using communication tools, such as SBAR, accurate reports can be sent to providers about changes in client condition and lab values.
  22. 22. Communication • It is vital to educate clients and their families about their actions related to medication, adverse effects, potential interactions, administration times and route. • Care providers need to be educated on all medications to be administered. • Be aware of abbreviations and potential for misunderstandings. Write out medication information and orders. Not all abbreviations are commonly understood.
  23. 23. Documentation Documentation refers to: • A method of communication necessary to accurately represent an updated, current version of a client’s medication regimen • A communication tool for health care providers and caregivers to be aware of client medication history and support an accurate record of medications administered • A critical part of the medical record identifying medication reconciliation in transitions of care
  24. 24. Documentation Documentation is used for: • The identification and recording of new medications, ongoing medications, changes in dosage or route of administration • Ensuring that medication is recorded at the time of administration, never in advance for safety and accuracy • Monitoring points for efficacy of medications and observation for potential adverse reactions
  25. 25. Documentation • Accurate documentation of medication administration allows for a seamless flow of providers regarding a critical aspect of care. • Documentation aids in key client identifiers and labeling of medications with vital pieces of information, crucial to safety principles.
  26. 26. Tips and Strategies for Safe Medication Administration • Understand that medication errors are preventable. • Correctly identify the client using two approved identifiers. • Be extra cautious when the environment is very busy and active. • Eliminate interruptions and distractions, focus on the task at hand.
  27. 27. Tips and Strategies for Safe Medication Administration • Be aware of client’s medication allergy history and be prepared to act in the event of an untoward reaction. • When preparing medications, assess for expiration dates. • Observe storage instructions for medications. Keep in a cool, dry environment or refrigerate as advised per pharmacy.
  28. 28. Tips and Strategies for Safe Medication Administration • Do not crush sustained or extended release medications for oral or NG/PEG tube administration. • Administer medications in a timely manner to maintain a constant blood level. National guidelines advise within ½ hour before and ½ hour after prescribed administration time.
  29. 29. Tips and Strategies for Safe Medication Administration • Dispense medications from properly labeled containers into medicine cups, never directly into the client’s hands. • Do not leave medications out at the bed or chair side to take later. Assess client’s condition prior to preparing medications. • Pay close attention to pharmacy instructions concerning medication administration in relation to meals, potential loss of balance or sedation.
  30. 30. Tips and Strategies for Safe Medication Administration • Remember the 6 “Rights” of medication administration. • Check medications at time of identification, at time of dispensing and before administering. • Ask questions if anything in the medication process seems unclear. Utilize resources of information: providers, colleagues, managers or reference materials.
  31. 31. Medication Administration Scenarios • Susan, a private duty registered nurse, has prepared Mr. Brown’s 10 a.m. medications. After performing a triple check in preparing the medications, Susan hands Mr. Brown the medication cup with a glass of water. He states, “I’ve never taken this red pill.” The best course of action for Susan would be to: A. Take the medications from the client and explain that she needs to ask him questions and verify that all the medications again are correct before administration. B. Give the medications because she had performed a triple check. C. Give the medications because the red pill is probably just a new generic substitute. D. Give the medications because she noticed Mr. Brown seems to be more confused lately.
  32. 32. Medication Administration Scenarios • Susan, a private duty registered nurse, has prepared Mr. Brown’s 10 a.m. medications. After performing a triple check in preparing the medications, Susan hands Mr. Brown the medication cup with a glass of water. He states, “I’ve never taken this red pill.” The best course of action for Susan would be to: A. Take the medications from the client and explain that she needs to ask him questions and verify that all the medications again are correct before administration. B. Give the medications because she had performed a triple check. C. Give the medications because the red pill is probably just a new generic substitute. D. Give the medications because she noticed Mr. Brown seems to be more confused lately.
  33. 33. Medication Administration Scenarios • Charlotte, a licensed practical nurse, is caring for Mrs. Hudson in her home for the first time. Charlotte is preparing 8 a.m. medications for the client when she notes that the levothyroxine is in an amber pill bottle with a handwritten label, identifying the medication as levothyroxine. The best course of action for the nurse to take is: A. Hold the medication and tell Mrs. Hudson to obtain a refill. B. Give the medication because Mrs. Hudson has taken the medication for many years. C. Give the medication then educate the client that all medications must remain in their original prescription bottle. D. Help Mrs. Hudson to find the original prescription bottle labeled by the dispensing pharmacy and administer only after the medication is properly identified. Report the situation to the client’s designated caregiver and provide education regarding safe medication administration.
  34. 34. Medication Administration Scenarios • Charlotte, a licensed practical nurse, is caring for Mrs. Hudson in her home for the first time. Charlotte is preparing 8 a.m. medications for the client when she notes that the levothyroxine is in an amber pill bottle with a handwritten label, identifying the medication as levothyroxine. The best course of action for the nurse to take is: A. Hold the medication and tell Mrs. Hudson to obtain a refill. B. Give the medication because Mrs. Hudson has taken the medication for many years. C. Give the medication then educate the client that all medications must remain in their original prescription bottle. D. Help Mrs. Hudson to find the original prescription bottle labeled by the dispensing pharmacy and administer only after the medication is properly identified. Report the situation to the client’s designated caregiver and provide education regarding safe medication administration.
  35. 35. Agencies Governing Medication Safety • Centers for Disease Control and Prevention (CDC): – Promotion of safe injection practices – State prescription drug laws – Drug overdoses – Medication safety program • Federal Food and Drug Administration (FDA): – Medication guides – Drug recalls – Medication Errors – Labeling and Black Box Warnings – Drug shortages
  36. 36. Agencies Governing Medication Safety • Drug Enforcement Agency (DEA): – National Drug Threat Assessment Summary – Registration for practitioners – National alerts • State Government – Programs and laws vary by individual state – Serve similar functions as the FDA – Drug testing – Health and safety codes
  37. 37. Medication Errors - Causes • “Medication errors usually occur because of multiple, complex factors. All parts of the health care system—including health professionals and patients—have a role to play in preventing medication errors.” Carol Holquist, R.Ph. Director of the Division of Medication Error Prevention FDA Center for Drug Analysis and Research
  38. 38. References • FDA 101: Medication Errors, Consumer Health Information, www.fda.gov/consumer, US Food and Drug Administration, February 20, 2009 • www.cdc.gov/medicationsafety, 2014 • Medical Dictionary for the Health Professions and Nursing © Farlex 2012 • National Institute for Occupational Safety and Health (NIOSH) Education and Information Division, Centers for Disease Control and Prevention Page last reviewed: June 26, 2013 Page last updated: June 24, 2011
  39. 39. References • SBAR Communication, info@saferhealthcare.com, 2015 • Patient Safety, Michigan Department of Community Health, Michigan.gov, State of Michigan, 2015 • Medline Plus, A service of the U.S. National Library of Medicine, National Institutes of Health www.nlm.nih.gov/medlineplus/drugsafety, 2015 • National Patient Safety Goals, Standards, The Joint Commission, www.jointcommission.org, 2015
  40. 40. References • Safety and Heath Topics - Culture of Safety, www.osha.gov, 2011 • Institute for Safe Medication Practices, www.ismp.org, 2015 • Medication Safety, www.bingimages.com, 2015

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