MEDICATION ERRORS: PREVENTING AND RESPONDING DSN KEVIN DOBI, MS, APRN Copyright © 2014 by Mosby, an...

MEDICATION ERRORS:PREVENTING AND RESPONDING

DSN KEVIN DOBI , MS, APRN

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Chapter 5

Medication errors Institute of Medicine studies (1999, 2006)

Adverse drug reactions Allergic reaction Idiosyncratic reaction

Adverse Drug Event


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Classroom Response Question


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In the 2006 Institute of Medicine Study, it was estimated that some form of medication error resulted in harm to how many patients?

A. 400,000B. 800,000C. 1 millionD. 1.5 million

PreventableCommon cause of adverse health care

outcomesMore potential for harm with “high-alert”

medications

Medication Errors


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Errors can occur during any step of medication process: Procuring Prescribing Transcribing Dispensing Administering Monitoring

Issues Contributing to Errors


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Organizational issuesEducational system issuesSociologic factors

Issues Contributing to Errors (cont’d)


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No error, although circumstances or events occurred that could have led to an error

Medication error that causes no harmMedication error that causes harmMedication error that results in death

Types of Medication Errors


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Multiple systems of checks and balancesLegible and correct ordersAppropriate consultationCheck medication order three times“Six Rights” of medication administration

Preventing Medication Errors


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Minimize verbal or telephone orders Repeat order to prescriber Spell drug name aloud Speak slowly and clearly

List indication next to each orderAvoid medical shorthand, including

abbreviations and acronyms

Preventing Medication Errors (cont’d)


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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 prescriber for clarification



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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 tenfold dose increase



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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



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Take time to learn special administration techniques of certain dosage forms

Always verify new medication administration records



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Always listen to and honor any concerns expressed by patients regarding medications

Check patient allergies and identification



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The nurse is administering a drug that has been ordered as follows: “Give 10 mg on odd-numbered days and 5 mg on even-numbered days.” When the date changes from May 31 to June 1, what should the nurse do?

A. Give 10 mg because June 1 is an odd-numbered day

B. Hold the dose until the next odd-numbered dayC. Change the order to read “Give 10 mg on even-

numbered days and 5 mg on odd-numbered days”

D. Consult the prescriber to verify that the dose should alternate each day, no matter whether the day is odd- or even-numbered

Report to prescriber and nursing management

Document error per policy and procedureFactual documentation only

Medication administered Actual dose Observed changes in patient condition Prescriber notified/follow-up orders

Reporting Medication Errors


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External reporting of errors USP MERP (United States Pharmacopeia

Medication Errors Reporting Program) MedWatch, sponsored by the FDA Institute for Safe Medication Practices (ISMP) The Joint Commission

Reporting Medication Errors (cont’d)


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The nursing student realizes 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 first?

A. Notify the patient’s physicianB. Notify the clinical facultyC. Take the patient’s blood pressureD. Continue to monitor the patient

Continuous assessment and updating of patient medication information Verification Clarification Reconciliation

Medication Reconciliation


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Should be done at each stage of health care delivery: Admission Status change Patient transfer within or between

facilities/provider teams Discharge

Medication Reconciliation (cont’d)


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Notification of patientsPossible consequences for nurses

Ethical Issues


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MEDICATION ERRORS: PREVENTING AND RESPONDING DSN KEVIN DOBI, MS, APRN Copyright © 2014 by Mosby, an...

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