Chapter 5 Medication Errors Preventing and Responding Copyright

  • Slides: 28
Download presentation
Chapter 5 Medication Errors: Preventing and Responding Copyright © 2017, Elsevier Inc. All rights

Chapter 5 Medication Errors: Preventing and Responding Copyright © 2017, Elsevier Inc. All rights reserved.

Adverse Drug Event Medication errors Institute of Medicine (IOM) studies (1999) Ø A follow-up

Adverse Drug Event Medication errors Institute of Medicine (IOM) studies (1999) Ø A follow-up study in 2010 showed no significant change in rates of preventable errors since the IOM study Ø Just culture Ø QSEN initiatives Ø Copyright © 2017, Elsevier Inc. All rights reserved. 2

Adverse Drug Event (Cont. ) Medication errors Adverse drug reactions (ADRs) Allergic reaction Ø

Adverse Drug Event (Cont. ) Medication errors Adverse drug reactions (ADRs) Allergic reaction Ø Idiosyncratic reaction Ø Copyright © 2017, Elsevier Inc. All rights reserved. 3

Adverse Drug Event (Cont. ) Copyright © 2017, Elsevier Inc. All rights reserved. 4

Adverse Drug Event (Cont. ) Copyright © 2017, Elsevier Inc. All rights reserved. 4

Audience Response System Question In a 2006 IOM study, it was estimated that some

Audience Response System Question In a 2006 IOM study, it was estimated that some form of medication error resulted in harm to how many patients? A. B. C. D. 400, 000 800, 000 1 million 1. 5 million Copyright © 2017, Elsevier Inc. All rights reserved. 5

Medication Errors Preventable Common cause of adverse health care outcomes Drugs commonly involved in

Medication Errors Preventable Common cause of adverse health care outcomes Drugs commonly involved in severe medication errors: central nervous system drugs, anticoagulants, and chemotherapeutic drugs More potential for harm with “high-alert” medications Copyright © 2017, Elsevier Inc. All rights reserved. 6

Medication Errors (Cont. ) SALAD (sound-alike, look-alike drugs) LASA (look-alike, sound-alike) Copyright © 2017,

Medication Errors (Cont. ) SALAD (sound-alike, look-alike drugs) LASA (look-alike, sound-alike) Copyright © 2017, Elsevier Inc. All rights reserved. 7

Issues Contributing to Errors can occur during any step of medication process Procuring Ø

Issues Contributing to Errors can occur during any step of medication process Procuring Ø Prescribing Ø Transcribing Ø Dispensing Ø Administering Ø Monitoring Ø Copyright © 2017, Elsevier Inc. All rights reserved. 8

Issues Contributing to Errors (Cont. ) Organizational issues Educational system issues Sociologic factors Use

Issues Contributing to Errors (Cont. ) Organizational issues Educational system issues Sociologic factors Use of abbreviations Copyright © 2017, Elsevier Inc. All rights reserved. 9

Types of Medication Errors No error, although circumstances or events occurred that could have

Types of Medication Errors No error, although circumstances or events occurred that could have led to an error Medication error that causes no harm Medication error that causes harm Medication error that results in death Copyright © 2017, Elsevier Inc. All rights reserved. 10

Preventing Medication Errors Multiple systems of checks and balances should be implemented to prevent

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. Copyright © 2017, Elsevier Inc. All rights reserved. 11

Preventing Medication Errors (Cont. ) Nurses need to always check the medication order three

Preventing Medication Errors (Cont. ) Nurses need to always check the medication order three times before giving the drug. The six rights of medication administration should be used consistently. Copyright © 2017, Elsevier Inc. All rights reserved. 12

Preventing Medication Errors (Cont. ) Assessment Two patient identifiers Do not administer if you

Preventing Medication Errors (Cont. ) 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. Ø Spell drug name aloud. Ø Speak slowly and clearly. Ø List indication next to each order. Copyright © 2017, Elsevier Inc. All rights reserved. 13

Preventing Medication Errors (Cont. ) Never assume anything about items not specified in a

Preventing Medication Errors (Cont. ) 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. Copyright © 2017, Elsevier Inc. All rights reserved. 14

Preventing Medication Errors (Cont. ) NEVER use a “trailing zero” with medication orders. Do

Preventing Medication Errors (Cont. ) NEVER use a “trailing zero” with medication orders. Do not use 1. 0 mg; use 1 mg. Ø 1. 0 mg could be misread as 10 mg, resulting in a 10 fold dose increase. Ø Copyright © 2017, Elsevier Inc. All rights reserved. 15

Preventing Medication Errors (Cont. ) ALWAYS use a “leading zero” for decimal dosages. Do

Preventing Medication Errors (Cont. ) ALWAYS use a “leading zero” for decimal dosages. Do not use. 25 mg; use 0. 25 mg. Ø. 25 mg may be misread as 25 mg. Ø Copyright © 2017, Elsevier Inc. All rights reserved. 16

Preventing Medication Errors (Cont. ) Take time to learn special administration techniques of certain

Preventing Medication Errors (Cont. ) Take time to learn special administration techniques of certain dosage forms. Always verify new medication administration records. Copyright © 2017, Elsevier Inc. All rights reserved. 17

Preventing Medication Errors (Cont. ) Always listen to and honor any concerns expressed by

Preventing Medication Errors (Cont. ) Always listen to and honor any concerns expressed by patients regarding medications. Check patient allergies and identification. Copyright © 2017, Elsevier Inc. All rights reserved. 18

Audience Response System Question The nurse is administering a drug that has been ordered

Audience Response System Question 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 day. C. Change the order to read: “Give 10 mg on evennumbered 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 Copyright © 2017, Elsevier Inc. All rights reserved. 19

Reporting Medication Errors Report to prescriber and nursing management. Document error per policy and

Reporting Medication Errors Report to prescriber and nursing management. Document error per policy and procedure. Factual documentation only Medication administered Ø Actual dose Ø Observed changes in patient condition Ø Prescriber notified and follow-up orders Ø Copyright © 2017, Elsevier Inc. All rights reserved. 20

Reporting Medication Errors (Cont. ) External reporting of errors United States Pharmacopeia Medication Errors

Reporting Medication Errors (Cont. ) External reporting of errors United States Pharmacopeia Medication Errors Reporting Program Ø Med. Watch, sponsored by the Food and Drug Administration Ø Institute for Safe Medication Practices Ø The Joint Commission Ø Copyright © 2017, Elsevier Inc. All rights reserved. 21

Audience Response System Question The nursing student realizes that she has given a patient

Audience Response System Question 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. B. C. D. Notify the patient’s physician. Notify the clinical faculty. Take the patient’s blood pressure. Continue to monitor the patient. Copyright © 2017, Elsevier Inc. All rights reserved. 22

Preventing Pediatric Medication Errors Report all medication errors. Know the drug thoroughly. Follow the

Preventing Pediatric Medication Errors Report all medication errors. Know the drug thoroughly. Follow the six rights of medication administration. Avoid verbal orders in general. Avoid distractions. Communicate with everyone. Copyright © 2017, Elsevier Inc. All rights reserved. 23

Medication Reconciliation Continuous assessment and updating of patient medication information Verification Ø Clarification Ø

Medication Reconciliation Continuous assessment and updating of patient medication information Verification Ø Clarification Ø Reconciliation Ø Copyright © 2017, Elsevier Inc. All rights reserved. 24

Medication Reconciliation (Cont. ) Process in which medications are “reconciled” at all points of

Medication Reconciliation (Cont. ) Process in which medications are “reconciled” at all points of entry and exit to or from a health care entity Patients provide a list of all the medications they are currently taking (including herbals and overthe-counter drugs). Prescriber then assesses the medications and decides if they are to be continued upon hospitalization. Copyright © 2017, Elsevier Inc. All rights reserved. 25

Medication Reconciliation (Cont. ) Designed to ensure that there are no discrepancies between what

Medication Reconciliation (Cont. ) Designed to ensure that there are no discrepancies between what the patient was taking at home and in the hospital Copyright © 2017, Elsevier Inc. All rights reserved. 26

Medication Reconciliation (Cont. ) Should be done at each stage of health care delivery:

Medication Reconciliation (Cont. ) Should be done at each stage of health care delivery: Admission Ø Status change (e. g. , from critical to stable) Ø Patient transfer within or between facilities or provider teams Ø Discharge (the latest medication list should be provided to the patient to take to his or her next health care provider) Ø Copyright © 2017, Elsevier Inc. All rights reserved. 27

Ethical Issues Notification of patients Possible consequences for nurses Copyright © 2017, Elsevier Inc.

Ethical Issues Notification of patients Possible consequences for nurses Copyright © 2017, Elsevier Inc. All rights reserved. 28

CHAPTER 5 Medication Errors Preventing and Responding NDEGCHAPTER 5 Medication Errors Preventing and Responding NDEG
Chapter 5 MEDICATION ERRORS PREVENTING AND RESPONDING DSNChapter 5 MEDICATION ERRORS PREVENTING AND RESPONDING DSN
Medication errors Medication side effects Medication incidents WhatMedication errors Medication side effects Medication incidents What
Medication Errors Medication errors can occur at manyMedication Errors Medication errors can occur at many
Medication Labels Reading Medication Labels Medication labels varyMedication Labels Reading Medication Labels Medication labels vary
Responding to Crisis Responding to Crisis Responding toResponding to Crisis Responding to Crisis Responding to
Responding to Crisis Responding to Crisis Responding toResponding to Crisis Responding to Crisis Responding to
Medication Management and Medication Errors in Assisted LivingMedication Management and Medication Errors in Assisted Living
Medication Error Reporting Systems and Disclosing Medication ErrorsMedication Error Reporting Systems and Disclosing Medication Errors
Preventing Medication Errors in Pediatric and Neonatal PatientsPreventing Medication Errors in Pediatric and Neonatal Patients
MEDICATION ERRORS A medication error is any preventableMEDICATION ERRORS A medication error is any preventable
Module 12 Medication Pass No Interruptions Medication ErrorsModule 12 Medication Pass No Interruptions Medication Errors
Medication Errors Kimberly Nix Andrew Tipton Introduction MedicationMedication Errors Kimberly Nix Andrew Tipton Introduction Medication
ERRORS AND APPROXIMATIONS ERRORS AND APPROXIMATIONS INTRODUCTION ERRORSERRORS AND APPROXIMATIONS ERRORS AND APPROXIMATIONS INTRODUCTION ERRORS
Preventing Medication Errors in Cancer Chemotherapy Learning ObjectivesPreventing Medication Errors in Cancer Chemotherapy Learning Objectives
Preventing Medication Errors in LongTerm Care Facilities IlenePreventing Medication Errors in LongTerm Care Facilities Ilene
Preventing Medication Errors A 21 Billion Opportunity MadePreventing Medication Errors A 21 Billion Opportunity Made
Preventing Medication Prescribing Errors Learning Objectives Describe errorPreventing Medication Prescribing Errors Learning Objectives Describe error
Oops I Did It Again Preventing Medication ErrorsOops I Did It Again Preventing Medication Errors
Data Errors Model Errors and Estimation Errors FrontiersData Errors Model Errors and Estimation Errors Frontiers
Syntax Errors Runtime Errors and Logic Errors YouSyntax Errors Runtime Errors and Logic Errors You
Preventing Dispensing Errors Learning Objectives Describe dispensing errorsPreventing Dispensing Errors Learning Objectives Describe dispensing errors
Dealing with Errors Syntax Errors Runtime Errors ErrorDealing with Errors Syntax Errors Runtime Errors Error
Programming Errors Errors of different types Syntax errorsProgramming Errors Errors of different types Syntax errors