Beyond the Five Rights of Medication Administration...5 Medication Administration Errors •...
Transcript of Beyond the Five Rights of Medication Administration...5 Medication Administration Errors •...
Beyond the Five Rights of Medication Administration
IMSN 2011
Presented by Michelle Mandrack, RN, MSN
ISMP
Are medication administration errors really that
bad…?
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Errors in the Medication Use Process
Prescribing Transcribing Dispensing Administering
33% 2%33%
Leape, et al., 1995
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Errors 39% 12% 11% 38%
48%
Harm 28% 11% 10% 51%
Intercepted
A Time Honored Tradition…
If the nurse had only followed the five rights…
Mistaken assumption is that the five rights is an error‐proof strategy!
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Medication Administration Errors• Medication administration accounts for up to one‐
third of nurses’ time— Most of the time = hunting and gathering
• 34% ‐ 38% of errors originate in the administration phase of the medication use process, and few are intercepted
• Overall, nurse scientists are noticeably absent from investigation of medication administration errors
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Bates, et al., 1995; Keohane, et al., 2008; Leape, et al., 1995; Pepper, 1995
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IV Medication Errors• IV medications are associated with 54% of
potential ADEs and increased risk of harm Drugs administered IV have immediate bioavailability Many “high‐alert" drugs, which have a narrow therapeutic
range, are given by infusion
• Recent high‐profile reports of injury and death have created new sense of urgency
Cohen, 2007; Fields, 2005; Kaushal, et al., 2001
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Preventing harm from infused medications
State Confirms Medical Error In Hospital Death Of Teen
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“Nurse didn’t bother to read the label”Dennis Quaid
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IV Medication Administration Errors
• Few prospective studies offer detailed analysis regarding the incidence and causes of IV medication administration errors
• Limited research findings suggest:– Errors associated with IV infusion pumps occur
frequently and are diverse in nature– Wrong rate errors are common, particularly with
injection of bolus doses
Han, 2005; Taxis, 2003
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What we know…
• Nurses spend 26.9% of their time on the critical task of medication administration (Keohane, Bane, Featherstone, et al., 2008)
• Approximately ⅔ of medica on administra on time related to drug delivery to the patient, and the other ⅓ spent preparing drugs for administration (Hendrich, Chow, Skierczynski, & Lu, Z., 2008)
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High‐Alert Medications• Develop a targeted list• Define strategies across the medication use system– Procurement– Prescribing– Transcription– Preparation– Labeling– Dispensing– Storage– Administration– Monitoring
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Rank Order of Error Reduction Strategies
Forcing functions and constraints
Automation and computerization
Standardization and protocols
Checklists and double‐check systems
Rules and policies
Education / information
“Be more careful”
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Independent Double‐Check
• Two nurses check the drug, dose, patient, line attachment, and pump settings before administration of a targeted high‐alert medication
Smetzer & Cohen, 2007
Independent Double‐Check
• Two nurses• Medication(s)• Medication administration record (MAR) or electronic MAR (eMAR)
• Bedside confirmation of patient identification and IV pump settings
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Questions
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References• Barker, K. N., Flynn, E. A., & Pepper, G. A., et al. (2002). Medication errors observed
in 36 health care facilities. Archives of Internal Medicine,162:1897‐1903.• Bates, D. W., Cullen, D. J., Laird, N., Petersen, L. A., Small, S. D., Servi, D., et al.
(1995). Incidence of adverse drug events and potential adverse drug events: implications for prevention. Journal of the American Medical Association, 274, 29‐34.
• Cohen, M. R. (Ed.) (2007). Medication errors (2nd ed.). Washington, DC: American Pharmacists Association.
• Fields, M., & Peterman, J. (2005). Intravenous medication safety system averts high‐risk medication errors and provides actionable data. Nursing Administration Quarterly, 29(1), 78‐87.
• Han, P. Y., Coombes, I. D., & Gree, B. (2005). Factors predictive of fluid administration errors in Australian surgical care wards. Quality and Safety in Health Care, 14, 179‐184.
• Hendrich, Chow, Skierczynski, & Lu, Z. (2008). A 36‐Hospital time and motion study: how do medical‐surgical nurses spend their time? The Permanente Journal,12 (3), 25‐34.
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References• Kaushal, R., Bates, D. W., Landrigan, C., McKenna, K. J., Clapp, M. D., Federico, F., et
al. (2001). Medication errors and adverse drug events in pediatric inpatients. Journal of the American Medical Association, 285(16), 2114‐2120.
• Keohane, CA, Bane, AD, Featherstone, E, Hayes, J, Woolf, S, Hurley, A., et.al. (2008). Quantifying Nursing Workflow in Medication Administration. Journal of Nursing Administration. 38(1) pp 19‐26.
• Kohn, L.T., Corrigan, J. M., & Donaldson, M. S. (Eds.) (1999). To err is human: building a safer health system.Washington, DC: National Academy Press.
• Leape, L. L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivam, T., et al. (1995). System analysis of adverse drug events. Journal of the American Medical Association, 274(1), 35‐43.
• Pepper, G. (1995). Errors in drug administration by nurses. American Journal of Health‐System Pharmacists, 52, 390‐395.
• Smetzer J, Cohen M. (2007) Preventing administration errors. In: Cohen M, ed. Medication Errors. 2nd ed. Washington DC: American Pharmacists Association; 2007:235.
• Taxis, K, & Barber, N. (2003). Causes of intravenous medication errors: an ethnographic study. Quality and Safety in Health Care, 12(5), 343‐347.
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