medication errors improving practices and patient safety

8/12/2019 Medication Errors Improving Practices and Patient Safety

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Copyright 2011 F.A. Davis Company

Daviss Drug Guide for Nurses, 12th Edition

Medication Errors

Improving Practices and

Patient Safety


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Medication Error

A preventable event that leads to

inappropriate medication use or patientharm.


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Causes of Medication Errors

NOTthe result of poor-quality staff!

Error-prone processes involved in the

medication use systemcontribute tomedication errors

Excellent, experienced practitioners make

mistakes


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Medication Errors

Most medication errors do not result in patient

harm

Some medication errors result in catastrophic

harm or death

High risk withHigh Alert Drugs highly toxic

drugs or drugs with a narrow therapeutic rangehave a high risk of causing devastating injury or

death; see Daviss Drug Guide for Nursesfor a

list of high alert drugs


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Selected Elements of the MedicationUse System

Communication

Labeling, packaging, and naming Administering medications (dose calculation,

timing, programming of infusion devices, etc.)

Monitoring drug levels and therapeutic ornontherapeutic responses

Thorough patient education


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Communication Problems

Similar-sounding or similar-looking names

Using package units like one tablet instead

of specific milligram dosage

Writing ambiguous or incomplete orders

Using abbreviations or unnecessary zeroes in

an order


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Misuse of Zeroes: Lead Dont Trail

Failing to use a leading zero: writing .2 mcg

instead of 0.2 mcg

Using an unnecessary trailing zero: 1.0 mg

instead of 1 mg

Can result in over- or under-dosing by a factorof 10


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Error-Prone Abbreviations Abbreviations can be misinterpreted

Does MS mean morphine sulfate or magnesium

sulfate?

U or u for units can look like a zero, especiallyif there is insufficient space between number andletter: 10u hand or computer-entered can look

like 100

See Daviss Drug Guide for Nursesfor a table oferror-prone abbreviations and safer alternatives


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Poorly Written Orders

Quickly, sloppily written orders historicallyhave been a source of medication errors

Even orders viewed on a computer screen orprinted out can be misread

Some orders lack important elements If you have to ask yourself what the order

means, ask the original prescriber, too!


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Sound-Alike, Look-Alike Drugs

Some drugs sound confusingly similar or

look very similar when printed or written

Amrinone, a cardiac inotropic agent, was

renamed inamrinone because of persistent

confusion with amiodarone Avoid phone orders!


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Labeling and Packaging Problems Packaging of drug products can look similar; the

wrong product could be picked up inadvertently

TALL MAN lettering helps prevent suchconfusion by highlighting certain syllables forespecially problematic drug pairs

Example: acetoHEXAMIDE andacetoZOLAMIDE

See Daviss Drug Guide for Nursesfor a list ofdrugs requiring Tall Man lettering


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Dose Miscalculations

Major cause of medication errors

Can be a mathematical error or a failure toconsider patients age; renal or hepatic

function; or other modifying factor

Includes miscalculation of dosage or rate ofadministration and misprogramming of

infusion pumps


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Incorrect Drug Administration

Dont forget the 5 Rights

Right drug

Right patient

Right dose

Right route

Right time


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Human and Environmental FactorsThat Influence Errors

Distractions

Poor staffing

Culture of perfection

Questioning physicians is tacitly discouraged

Punitive response to error (shame andblame)


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Prevention Strategies for Nurses

Clarify any order that is not obviously and

clearly legible

Do not accept orders with the abbreviation

u, U, orIUfor units

Clarify abbreviated drug names or dosingfrequencies

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Prevention Strategies for Nurses (Contd)

If dose requires >3 or


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Clarify any order that does not include metric

weight (mg, mcg, gram, etc.), dosing frequency, or

route of administration

Orders should include the indication clarify with

prescriber

If the facility uses handwritten systems, check thenurse's/clerk's transcription against the original

order; make sure stray marks or initials do not

obscure the original order

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Do not start a patient on a new medication by

borrowing medications from another patient

Doing so bypasses the double check provided

by the pharmacists review of the order

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Always check the patient's name band/bar

code before administering medications

Verbally addressing a patient by name does

not provide sufficient identification

Always check for allergies

Consider drug/food interactions and educate

patient

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Be sure to fully understand any drug

administration device before using it This includes infusion pumps, inhalers, and

transdermal patches

Have a second practitioner independentlycheck original order, dosage calculations,

and infusion pump settings for high alertmedications

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Preventing Med Errors in the Home

Medication errors occur in the home, too;educate patients about safe medication use

Important elements include Generic and brand name of drug

Purpose of drug

Dosage and how to self-administer drug

Minor and serious side effects and what to do if they occur

Follow-up care, including drug-level monitoring

See Daviss Drug Guide for Nursesfor moreinformation about patient education

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Copyright 2011 F A Davis Company

Reporting Medication Errors

Making an error does not make you a bad

nurse; excellent practitioners, pharmacists,

physicians, and nurses make mistakes

Data about med errors will help initiate better

prevention strategies

Report errors onlinehttps://www.accessdata.fda.gov/scripts/medwatch/

Or by phone: 1-800-FDA-1088

medication errors improving practices and patient safety

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