ComForCare explains the common errors when it comes to medication.

1. They can be avoided.
Medication Errors

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. Objectives
• Define the role of communication in
medication safety
• Identify state and federal agencies
responsible for medication safety

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. 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. 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. 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. 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. 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. 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. 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. The “Rights” of Medication Administration

13. The “Rights” of Medication Administration
• Right dose
• Right time
• Right route
• Right medication
• Right client
• Right documentation

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. Prevention Strategies
• Client identification
• Communication
• Physician orders
• Focus on medication preparation
• Correct documentation

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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