Medication Error: It is 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 and systems,
including: prescribing, order communication, product labeling, packaging and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring and use.
MEDICATION ERROR REPORT PROCESS
- Inform Head/Charge nurse
- Incident report (OVR) to be made
- Complete EMERF through alert system
-Assess & Monitor the patient
- Inform MRP/SOD
- Take action to solve the error
- Must be aware of:
*No disciplinary action to be taken
for the staff reported within 24 hours
SOD (Supervisor on Duty)
- Must be aware of the incident
- Complete OVR
- Insure EMERF is done
- Inform Pharmacy
MRP (Most Responsible Physician)
- To take Appropriate action
- Fills in the designated area of EMERF the
appropriate action taken
- Inform Pharmacy immediately if the error
reach the patient and have necessitated
- Investigate the case
- Submit the written report to QPSD/Risk management
- Do RCA
- Provide recommendation to resolve the problem
- Approve the learned action plan
- Disseminated learned action to all unit
TYPE OF MEDICATION ERROR
1. 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 .
1. PRESCRIBING ERRORS
Occurs when prescriber orders drug for specific patient
route of administration
length of therapy
number of doses
inadequate or incorrect instructions for use
2. OMISSION ERRORS
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.
3. WRONG TIME ERRORS
Standardized administration times
Acceptable interval surrounding scheduled time.
patient is away care area for test.
medication is not available at time it is due.
4. UNAUTHORIZED DRUG
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.
5. IMPROPER DOSE ERRORS
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
6. WRONG DOSAGE FORM
Doses administered as different form than
8. WRONG ADMIN TECHNIQUE ERRORS
Subcutaneous injection that is given too deep
Intravenous (IV) drug is allowed to infuse via gravity
instead of using an IV pump.
Instilling eye drops in wrong eye.
9. DETERIORATED DRUG
Monitoring expiration dates is very important.
Refrigerated drugs stored at room temperature may
decompose & lose efficacy.
10. MONITORING ERRORS
Inadequate drug therapy review.
Ordering serum drug levels but not reviewing
Not ordering drug levels when required.
Prescribing antihypertensive agent & then failing
to check blood pressure.
11. COMPLIANCE ERRORS
Failure to adhere to prescribed drug
Patient does not complete antibiotics
therapy-saves a few doses.
Errors that cannot be placed into category.
Medication dispensed without
adequate patient education.
UNAPPROVED ABBREVIATIONS LEADING
TO MEDICATION ERRORS:
Just because you cannot do it
Does NOT mean you will not do
اليوم ذلك تفعل لم ألنك فقط
ينب ال هذا
ما ًايوم ذلك تفعل لن انك
If you are not willing to learn, No one can
If you are determined to learn, No one can
stop you …!!
ان احد يستطيع لن تتعلم ان على ًاعازم تكن لم ان
سيوقفك من اليوجد فإنه تتعلم أن قررت إذا
NO ONE CAN MOTIVATE….
IF YOU ARE NOT WILLING TO
DO YOUR SELF…