Medication Errors - Preventing and Responding - Week 1 Pharm 2

MEDICATION ERRORS: PREVENTING AND RESPONDING Chapter 6  GENERAL IMPACT OF ERRORS Landmark study by Institute of Medicine (IOM) in 1999 Follow-up study in 2010 showed no significant change in rates of preventable errors since the IOM study....

MEDICATION ERRORS: PREVENTING AND RESPONDING Chapter 6  GENERAL IMPACT OF ERRORS Landmark study by Institute of Medicine (IOM) in 1999 Follow-up study in 2010 showed no significant change in rates of preventable errors since the IOM study.  Recognizes that systems are generally at fault when error occurs Need for accountability Remediation of Workplace culture JUST Reporting structure CULTURE Management behaviour When professionals do not follow policies or have repeated errors Need for accountability Remedial education  ADVERSE DRUG EVENT General term Encompasses all types of clinical problems resulting from medication use Adverse drug reactions (ADRs) Allergic reaction Idiosyncratic reaction Medication errors TEXTBOOK FIGURE 6-1  Preventable Common cause of adverse health care outcomes Drugs commonly involved MEDICATION in severe medication ERRORS errors: central nervous system drugs anticoagulants chemotherapeutic drugs  MEDICATION ERRORS CON T’D More potential for harm with “high- alert” medications SALAD (sound-alike, look-alike drugs) LASA (look-alike, sound-alike) TALLman lettering  ISSUES CONTRIBUTING TO ERRORS Errors can occur during any step of medication process Procuring Prescribing Transcribing Dispensing Administering Monitoring  ISSUES CONTRIBUTING TO ERRORS CONT’D Organizational issues Educational system issues Sociological factors Use of abbreviations  TYPES OF MEDICATION ERRORS Near Did not reach the patient, Results in miss no harm No harm Reaches patient, Results in no harm event Medicatio n Error Causes harm Critical Incident Results in serious harm  PREVENTING MEDICATION ERRORS Multiple systems of checks and balances should be implemented to prevent medication errors. Prescribers must write legible orders that contain correct information, or orders should be entered electronically. Authoritative resources such as pharmacists or current (within the past 3 to 5 years) drug references or literature must be consulted.  PREVENTING MEDICATION ERRORS CONT’D Nurses need to always check the medication order three times before giving the drug. Faculty members should not be the student’s research source regarding medications. The rights of medication administration should be used consistently.  R E S P ON D IN G T O, R E P ORT I N G, AN D D OC U M E N T IN G M E D I C AT I ON E R R OR S Professional responsibility Follow facility policy Follow-up procedures or tests Nurse’s highest priority is patient’s physiological status and safety.  R E S P ON D IN G T O, R E P ORT I N G, AN D D OC U M E N T IN G M E D I C AT I ON C ON T ’ D Complete all necessary forms. Document with factual information: accurate, thorough, and objective. Avoid using judgmental words (e.g., error). Note observed changes in patient’s physical or mental status. Document that the prescriber was notified and any follow-up actions or orders that were implemented Ongoing patient monitoring The Institute for Safe Medication Practices Canada  R E C OM M E N D E D GU ID E L IN E S F OR T IM E LY M E D IC AT ION A D M I N IS T RAT ION Time Critical Scheduled Medications Facility-defined medications: Administer at exact time when necessary (e.g. rapid acting insulin), otherwise within 30 minutes before or after scheduled time. Non-Critical Scheduled Medications Daily, weekly, monthly: Administer within 2 hours before or after scheduled time Medications prescribed more frequently than daily but no greater than Q4H: Administer within ONE hour before or after scheduled time.  MEDICATION RECONCILIATION Continuous assessment and updating of patient medication information Verification Clarification Reconciliation  M E D I C AT ION R E C ON C I L I AT I ON C ON T ’ D Process in which medications are “reconciled” should occur at: Entry into the facility Transfer into the facility Into or out of the ICU Discharge  MEDICATION RECONCILIATION PROCESS Patients provide a list of all the medications they are currently taking (including natural health products and over-the-counter drugs). Prescriber then assesses the medications and decides if they are to be continued upon hospitalization. Designed to ensure that there are no discrepancies between what the patient  ETHICAL ISSUES Notification of patients Possible consequences for nurses  PREVENTING MEDICATION ERRORS Assessment Two patient identifiers Do not administer if you did not draw up or prepare yourself. Minimize verbal or telephone orders. Repeat order to prescriber. Spell drug name aloud. Speak slowly and clearly.  PREVENTING MEDICATION ERRORS List indication next to each order. Avoid abbreviations. Never assume anything about items not specified in a drug order (e.g., route). Do not hesitate to question a medication order for any reason when in doubt. Do not try to decipher illegibly written orders; contact the prescriber for clarification.  PREVENTING MEDICATION ERRORS Never use a “trailing zero” with medication orders. Do not use 1.0 mg; use 1 mg. 1.0 mg could be misread as 10 mg, resulting in a 10-fold dose increase. Always use a “leading zero” for decimal dosages. Do not use.25 mg; use 0.25 mg..25 mg may be misread as 25 mg.  PREVENTING MEDICATION ERRORS Take time to learn special administration techniques of certain dosage forms. Always verify new medication administration records. Always listen to and honor any concerns expressed by patients regarding medications. Check patient allergies and identification.  that she has given a patient a double dose of an antihypertensive medication. The tablet was supposed to be cut in half, but the student forgot and administered the entire tablet. The patient’s blood pressure just before the dose was 146/98 mm Hg. What should the student nurse do PRACTICE QUESTION first? A. Notify the patient’s physician. B. Notify the clinical faculty or preceptor. C. Take the patient’s blood pressure. D. Continue to monitor the  PREVENTING PEDIATRIC MEDICATION ERRORS Report all medication errors. Know the drug thoroughly. Follow the Ten Rights of medication administration. Avoid verbal orders in general. Avoid distractions. Communicate with everyone.