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SAFETY IN MEDICATION
ADMINISTRATION
PRESENTED BY MN KIRANMAI, QI OFFICER, QPS
DEPARTMENT, KFCH-GIZAN
QUALITY AND PATIENT SAFETY-KFCH
WHAT IS MEDICATION ERROR?
2
• Any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the
control of the health care professional, patient, or consumer.
• Such events may be related to professional practice, health care
products, procedures, and systems, including prescribing; order
communication; product labeling, packaging, and nomenclature;
compounding; dispensing; distribution; administration;
education; monitoring; and use.
QUALITY AND PATIENT SAFETY-KFCH
WHO CAN ADMINISTER MEDICATIONS?
3
• Physicians
• Nurses
• Certified medication technicians
• Patients
• Patient family
QUALITY AND PATIENT SAFETY-KFCH
COMMON REASONS WHY ERRORS OCCUR
WITH MEDICATION ADMINISTRATION
QUALITY AND PATIENT SAFETY-KFCH 4
Error-provoking conditions influencing administration errors included:
 Inadequate written communication (prescriptions, documentation,
transcription)
 Medication labelling and packing (LASA, wrong labelling)
 Problems with medicines supply and storage (pharmacy dispensing errors
and ward stock management)
 High perceived workload
 Problems with ward-based equipment (access, functionality)
 Patient factors (availability, acuity)
 Staff health status (fatigue, stress)
 Interruptions/distractions during drug administration
TYPES OF MEDICATION ADMINITRATION ERRORS
(7 Why’s People Do Known Medication Errors Invariably- DK
methodology)
• Wrong dose
• Wrong choice
• Wrong drug
• Wrong route
• Wrong technique
• Wrong time
• Wrong frequency
• Preparation errors
• Drug-drug interaction
• Known allergy
• Missed dose
• Equipment failure
• Inadequate monitoring
5QUALITY AND PATIENT SAFETY-KFCH
SAFE MEDICATION ADMINISTRATION
6QUALITY AND PATIENT SAFETY-KFCH
SAFE MEDICATION ADMINISTRATION
• Safe medication administration is a process where
the right medication is given to the patient as
follows:
• To Right patient
• Right drug
• Right dose
• At Right time
• Right route
• At Right frequency
• Right Education to patient
• Know right reason
• Assess right response
• Respect patient’s right to refuse
• With right documentation
7QUALITY AND PATIENT SAFETY-KFCH
10 RIGHTS OF MEDICATION
ADMINISTRATION
8QUALITY AND PATIENT SAFETY-KFCH
9QUALITY AND PATIENT SAFETY-KFCH
10QUALITY AND PATIENT SAFETY-KFCH
11QUALITY AND PATIENT SAFETY-KFCH
12QUALITY AND PATIENT SAFETY-KFCH
13QUALITY AND PATIENT SAFETY-KFCH
14QUALITY AND PATIENT SAFETY-KFCH
15QUALITY AND PATIENT SAFETY-KFCH
16QUALITY AND PATIENT SAFETY-KFCH
17QUALITY AND PATIENT SAFETY-KFCH
PREVENTING MEDICATION
ADMINISTRATION ERRORS
• Question any order that you considered incorrect
(may be unclear or inappropriate)
• Be knowledgeable about the medication that you
administer
• Keep the Narcotics in locked place
• Use only medications that are in clearly labeled
containers
• Return liquid that are cloudy in color to the
pharmacy
• Before administering medication, identify the
client correctly
• Ensure safety of high alert medications
• Use double check method by two nurses before
administering medication
• The nurse who prepares the drug administers it..
Only the nurse prepares the drug knows what the
drug is. Do not accept endorsement of
medication.
• Do not let some one else prepare medications of
your patient
• If the client vomits after taking the medication,
report this to the nurse in-charge or physician
• Do not leave the medication at the bedside. Stay
with the client until he takes the medications.
• Prepare medications for one patient at a time.
• Do not label the medicine by patient room
number or bed number
• Report all medication errors for prevention of
future occurrences
18QUALITY AND PATIENT SAFETY-KFCH
WHAT TO DO WHEN AN ERROR OCCURS
DURING MEDICATION ADMINISTRATION?
•Do not hide any
errors
•Report all errors
to immediate
supervisor
•Learn from
mistakes
•Document what
is the error in
patient medical
error
•Monitor patient
condition for
improvement
and document
every finding
•Follow
instructions
•Report any
changes to
physician
•Explain patient
about the error
(depending on
policy who must
disclose the
errors)
•Check vital
signs
•Ask patient to
report any
unusual
changes
First ensure
safety of
patient
Inform
physician for
instructions
Document
the error
and monitor
patient
REPORT
ERROR
19QUALITY AND PATIENT SAFETY-KFCH
MEDICATION ADMINISTRATION ERRORS
& JUST CULTURE
QUALITY AND PATIENT SAFETY-KFCH
LET’S LEARN FROM OUR MISTAKES
21QUALITY AND PATIENT SAFETY-KFCH
QUESTIONS???
22QUALITY AND PATIENT SAFETY-KFCH
23QUALITY AND PATIENT SAFETY-KFCH

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Safety in medication administration

  • 1. SAFETY IN MEDICATION ADMINISTRATION PRESENTED BY MN KIRANMAI, QI OFFICER, QPS DEPARTMENT, KFCH-GIZAN QUALITY AND PATIENT SAFETY-KFCH
  • 2. WHAT IS MEDICATION ERROR? 2 • Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. • Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. QUALITY AND PATIENT SAFETY-KFCH
  • 3. WHO CAN ADMINISTER MEDICATIONS? 3 • Physicians • Nurses • Certified medication technicians • Patients • Patient family QUALITY AND PATIENT SAFETY-KFCH
  • 4. COMMON REASONS WHY ERRORS OCCUR WITH MEDICATION ADMINISTRATION QUALITY AND PATIENT SAFETY-KFCH 4 Error-provoking conditions influencing administration errors included:  Inadequate written communication (prescriptions, documentation, transcription)  Medication labelling and packing (LASA, wrong labelling)  Problems with medicines supply and storage (pharmacy dispensing errors and ward stock management)  High perceived workload  Problems with ward-based equipment (access, functionality)  Patient factors (availability, acuity)  Staff health status (fatigue, stress)  Interruptions/distractions during drug administration
  • 5. TYPES OF MEDICATION ADMINITRATION ERRORS (7 Why’s People Do Known Medication Errors Invariably- DK methodology) • Wrong dose • Wrong choice • Wrong drug • Wrong route • Wrong technique • Wrong time • Wrong frequency • Preparation errors • Drug-drug interaction • Known allergy • Missed dose • Equipment failure • Inadequate monitoring 5QUALITY AND PATIENT SAFETY-KFCH
  • 6. SAFE MEDICATION ADMINISTRATION 6QUALITY AND PATIENT SAFETY-KFCH
  • 7. SAFE MEDICATION ADMINISTRATION • Safe medication administration is a process where the right medication is given to the patient as follows: • To Right patient • Right drug • Right dose • At Right time • Right route • At Right frequency • Right Education to patient • Know right reason • Assess right response • Respect patient’s right to refuse • With right documentation 7QUALITY AND PATIENT SAFETY-KFCH
  • 8. 10 RIGHTS OF MEDICATION ADMINISTRATION 8QUALITY AND PATIENT SAFETY-KFCH
  • 9. 9QUALITY AND PATIENT SAFETY-KFCH
  • 10. 10QUALITY AND PATIENT SAFETY-KFCH
  • 11. 11QUALITY AND PATIENT SAFETY-KFCH
  • 12. 12QUALITY AND PATIENT SAFETY-KFCH
  • 13. 13QUALITY AND PATIENT SAFETY-KFCH
  • 14. 14QUALITY AND PATIENT SAFETY-KFCH
  • 15. 15QUALITY AND PATIENT SAFETY-KFCH
  • 16. 16QUALITY AND PATIENT SAFETY-KFCH
  • 17. 17QUALITY AND PATIENT SAFETY-KFCH
  • 18. PREVENTING MEDICATION ADMINISTRATION ERRORS • Question any order that you considered incorrect (may be unclear or inappropriate) • Be knowledgeable about the medication that you administer • Keep the Narcotics in locked place • Use only medications that are in clearly labeled containers • Return liquid that are cloudy in color to the pharmacy • Before administering medication, identify the client correctly • Ensure safety of high alert medications • Use double check method by two nurses before administering medication • The nurse who prepares the drug administers it.. Only the nurse prepares the drug knows what the drug is. Do not accept endorsement of medication. • Do not let some one else prepare medications of your patient • If the client vomits after taking the medication, report this to the nurse in-charge or physician • Do not leave the medication at the bedside. Stay with the client until he takes the medications. • Prepare medications for one patient at a time. • Do not label the medicine by patient room number or bed number • Report all medication errors for prevention of future occurrences 18QUALITY AND PATIENT SAFETY-KFCH
  • 19. WHAT TO DO WHEN AN ERROR OCCURS DURING MEDICATION ADMINISTRATION? •Do not hide any errors •Report all errors to immediate supervisor •Learn from mistakes •Document what is the error in patient medical error •Monitor patient condition for improvement and document every finding •Follow instructions •Report any changes to physician •Explain patient about the error (depending on policy who must disclose the errors) •Check vital signs •Ask patient to report any unusual changes First ensure safety of patient Inform physician for instructions Document the error and monitor patient REPORT ERROR 19QUALITY AND PATIENT SAFETY-KFCH
  • 20. MEDICATION ADMINISTRATION ERRORS & JUST CULTURE QUALITY AND PATIENT SAFETY-KFCH
  • 21. LET’S LEARN FROM OUR MISTAKES 21QUALITY AND PATIENT SAFETY-KFCH
  • 23. 23QUALITY AND PATIENT SAFETY-KFCH

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