Focus on Pharmacology Essentials for Health Professionals Third

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Focus on Pharmacology: Essentials for Health Professionals Third Edition Chapter 11 Medication Errors and

Focus on Pharmacology: Essentials for Health Professionals Third Edition Chapter 11 Medication Errors and Prevention Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Medication Errors • Inappropriate or incorrect administration of drugs • Should be preventable through

Medication Errors • Inappropriate or incorrect administration of drugs • Should be preventable through effective controls • Can occur because of manufacturing mistakes • May result in pain, injury, or death • Medication errors occur more frequently than reported. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Medication Errors - 2 • First Stage of Medication Errors – Physicians or other

Medication Errors - 2 • First Stage of Medication Errors – Physicians or other persons prescribing the medication may be distracted or interrupted and provide incomplete orders. – Involves prescribing or ordering medication § Errors are most prevalent when: – Choosing a medication – Choosing its dosage – Choosing its schedule Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Medication Errors - 3 • Second Stage of Medication Errors – When the medication

Medication Errors - 3 • Second Stage of Medication Errors – When the medication is dispensed to patients or consumers § Can occur as a result of insufficient or inexperienced staffing and a lack of adequate time for patient counseling § Important to double-check medications against the medication administration record (MAR) Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Medication Errors - 4 • Third Stage of Medication Errors – When the medication

Medication Errors - 4 • Third Stage of Medication Errors – When the medication is administered and monitored for side effects – Common from nurses, others legally allowed to handle administration – May be caused by: § Poor communication § Misread paperwork § Similar labeling or packaging § Similar medication names – Other factors include similar labeling and packaging of products and medications with similar names. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Medication Errors -5 • Most common medication error is dosage. • Increased use of

Medication Errors -5 • Most common medication error is dosage. • Increased use of OTC drugs and herbals • Availability of drugs through the Internet • Errors – Must be reported as soon as they are noticed – Must be documented in the medical record § With signature of person responsible Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Causes of Medication Errors • Use of incorrect abbreviations • Miscommunication • Missing information

Causes of Medication Errors • Use of incorrect abbreviations • Miscommunication • Missing information • Lack of appropriate labeling • Environmental factors • Poor management Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Causes of Medication Errors continued • Wrong patient • Incorrect route • Incorrect drug

Causes of Medication Errors continued • Wrong patient • Incorrect route • Incorrect drug • Incorrect dose • Incorrect time • Incorrect technique • Incorrect information on patient chart Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Results of Medication Errors • Extended hospital stays • Higher costs • Increased separation

Results of Medication Errors • Extended hospital stays • Higher costs • Increased separation from family and normal activities • Harm to health care professional reputations • Financial penalties • Legal cases Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Documentation of Medication Errors • Should be clear and factual • Follow policies and

Documentation of Medication Errors • Should be clear and factual • Follow policies and procedure guidelines • Determine causes to prevent reoccurrence – Blame and judgment should be put aside. • Must include interventions undertaken Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Documentation of Medication Errors continued • MAR should be fully updated. • Incident or

Documentation of Medication Errors continued • MAR should be fully updated. • Incident or occurrence report completed – By person responsible for, or who observed the error • Root cause analysis (RCA) – – May prevent future mistakes Exactly what happened Why it happened What can be done to prevent its recurrence Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reporting Medication Errors • Legal and ethical responsibility of all staff members to report

Reporting Medication Errors • Legal and ethical responsibility of all staff members to report all medication errors • FDA coordinates reporting with Med. Watch – Allows anonymous participation • National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) – Has helped standardize reporting system Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reporting Medication Errors continued • Institute for Safe Medication Practices (ISMP) – Accepts reports

Reporting Medication Errors continued • Institute for Safe Medication Practices (ISMP) – Accepts reports about medication safety • The Joint Commission (TJC) – Requires hospitals to inform patients when they have been harmed because of errors – Established National Patient Safety Goals (NPSGs) Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Sentinel Events • Unexpected occurrences involving death, serious physical or psychological injury, or risk

Sentinel Events • Unexpected occurrences involving death, serious physical or psychological injury, or risk thereof. • Recognized by The Joint Commission (TJC) • Always investigated • Root cause analysis used to identify causes and needed interventions. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reducing and Preventing Medication Errors • Employ an adequate number of staff. • Use

Reducing and Preventing Medication Errors • Employ an adequate number of staff. • Use standardized measurement systems. • Use prospective error-tracking systems. • Clearly define a system for drug administration, ordering, and dispensing. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reducing and Preventing Errors • Compile medication profiles. • Provide suitable work environments. •

Reducing and Preventing Errors • Compile medication profiles. • Provide suitable work environments. • Use electronic medical records and e-prescription automatic surveillance measures. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reducing and Preventing Errors 2 • Reducing Errors in Health Care Facilities – Automation

Reducing and Preventing Errors 2 • Reducing Errors in Health Care Facilities – Automation § Allows drug storage cabinets to maintain an accurate inventory and security – Risk management departments § Minimize errors and examine risks Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reducing and Preventing Errors 3 • Reducing Errors in Health Care Facilities – Avoid:

Reducing and Preventing Errors 3 • Reducing Errors in Health Care Facilities – Avoid: § Expired medications § Transfer of medications between containers § Overstocking § Dangerous abbreviations § Reference materials that are not up to date Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors • Many medication errors are related to: – Certain

Strategies for Handling Medication Errors • Many medication errors are related to: – Certain populations § Children or older adults – Types of health care facilities Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors 2 • Steps can help in avoiding medication errors

Strategies for Handling Medication Errors 2 • Steps can help in avoiding medication errors and promoting safe administration of medications 1. Assessment § Patient use § Knowledge of medications § Body systems 2. Planning § Avoid unclear abbreviations. § Question unclear orders. § Refuse verbal orders. § Follow all policies and procedures. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors 3 • Steps can help in avoiding medication errors

Strategies for Handling Medication Errors 3 • Steps can help in avoiding medication errors and promoting safe administration of medications 3. Implementation § Eliminate distraction during adminstration. § Ensure right patient, time, frequency, dose, route, and drug are all exact. § Ensure accurate use and monitoring. 4. Evaluation § Assess for correct outcomes. § Determine adverse effects. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors 4 • Nine Categories of Medication Errors – –

Strategies for Handling Medication Errors 4 • Nine Categories of Medication Errors – – – A – having capacity to cause errors B – errors which occurred that did not reach patient C – reached patient without harm D – could have caused harm E – might have caused harm and required intervention Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors 5 • Nine Categories of Medication Errors – –

Strategies for Handling Medication Errors 5 • Nine Categories of Medication Errors – – F – might have caused harm and required hospitalization G – might have caused long-term harm H – required intervention to sustain life I – might have caused the patient’s death Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Strategies for Handling Medication Errors 6 • Most involve administration of an improper dose

Strategies for Handling Medication Errors 6 • Most involve administration of an improper dose (41%) • Nearly half of fatal medication errors occur in patients older than 60 years of age. – Many different medications may be used. – Multiple health care providers – Age-related physiology changes • Children also more likely to experience medication errors. – Doses are based on body weight (and prone to calculation errors). Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Fatal Medication Errors in Elderly • Figure 11 -1 Nearly half of fatal medication

Fatal Medication Errors in Elderly • Figure 11 -1 Nearly half of fatal medication errors occur in patients older than 60 years of age. • Next slide has picture of those most affected. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reconciling Medications • Polypharmacy – Receiving multiple medications, sometimes for the same condition, with

Reconciling Medications • Polypharmacy – Receiving multiple medications, sometimes for the same condition, with conflicting actions • Most common in older patients – Can occur with patients of all ages • Medication reconciliation – Keeping track of medications as health care providers are changed Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reconciling Medications 2 • Accurately listing all medications being taken to reduce – –

Reconciling Medications 2 • Accurately listing all medications being taken to reduce – – Duplications Dosing errors Omissions Interactions • Include prescription medications, OTC medications, herbal supplements, and vitamins Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Reconciling Medications 3 • The Joint Commission – Identified many serious medication errors related

Reconciling Medications 3 • The Joint Commission – Identified many serious medication errors related to medication reconciliation. – Encourages hospitals to document all patient medications during admission. – Patient medication lists communicated to all providers, inside and outside hospital. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Patient Education About Medications • Patients must understand medication – – Risks Benefits Administration

Patient Education About Medications • Patients must understand medication – – Risks Benefits Administration Adverse effects • When patients do not receive appropriate, direct education, they often resort to relying on printed information included on drug labels or package inserts, which they may not fully comprehend. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Patient Education About Medications 2 • Individualized patient counseling is essential. • Poor health

Patient Education About Medications 2 • Individualized patient counseling is essential. • Poor health literacy is a barrier to adequate patient care. • Best to provide thorough spoken instruction to each patient, which can then be followed up by providing complete written information. – Age-appropriate – Audiovisual teaching aids when available – Contact information of professionals to be notified in case of an adverse reaction Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved

Patient Education About Medications 3 • Patients should: – Always use specified medication devices

Patient Education About Medications 3 • Patients should: – Always use specified medication devices to administer their medications. – Be instructed to carry a list of all their prescription and OTC medications. – Be encouraged to ask questions. Copyright © 2018, 2013, 2008 Pearson Education, Inc. All Rights Reserved