Preventing Errors Related to Drug Administration

Learning Objectives

• Identify sources of errors related to drug administration

• Discuss prevention strategies to decrease the potential for drug administration errors

• Explain the role of interdisciplinary personnel in preventing drug administration errors

Preventing Drug Administration Errors

Nurses perform important functions that support safe medication use:• Document medication administration• Assess the patient’s response to medications and

notify prescribers• Educate patients and families about medication use

Depending on the institution and existing automation, nurses also may:

• Obtain and document the patient’s medication history• Reconcile medications prescribed upon admission,

transfer, and discharge• Transmit orders to the pharmacy• Transcribe orders and verify orders on the medication

administration record (MAR)

Preventing Drug Administration Errors

All members of the health care team involved in choosing the patients’ drug therapy, evaluating orders, and preparing medication must work together to ensure that the systems in place support safe medication use

Obtaining Patient InformationSafe administration of medication requires

accurate information• Patient Identification• Age, weight, and height

– Use one standard unit of measurement, preferably kilograms– Establish a standard routine for reweighing patients – When weight is critical, be sure it is accurate; be clear about

the source of a patient’s weight (e.g., measured, calculated, reported, estimated)

– Height also may be a critical measurement particularly in pediatrics

• Diagnoses– Some error types are less likely if practitioners know a

patient’s diagnoses– The nurse can match patients’ medication to their diagnoses

and ensure that each drug’s intended purpose makes sense• Pregnancy and lactation status

– Some drugs are teratogenic, causing fetal harm in utero– Many drugs transfer into breast milk and some pose a risk for the

infant

Obtaining Patient Information

Allergies– Drugs that cause severe allergic responses include antibiotics,

opioids, NSAIDs, vaccines, and insulin• The nurse should ask patient to describe the type of allergic

reaction previously experienced• True allergies, intolerances, and sensitivities are all generally

reported as “allergies”– An allergy may be missed when a drug contains two or more

medications (e.g., Vicodin contains hydrocodone and acetaminophen)

– OTC medications and herbal supplements should be included in patient information because they may cause allergic reactions

– Latex allergies: some rubber stoppers on vials contain latex– Document allergies prominently on the patient’s MAR and in

a standard location on the patient’s medical record

Obtaining Patient InformationCurrent Medications

• It can be difficult to get a complete list of medications, vitamins, nonprescription drugs, and herbals that the newly admitted patient uses– Patients may not accurately report all of their medications and

dosages– Patients may not want to report the use of home remedies or

herbals– Past medical records may not be up-to-date

• Other pharmacies or doctors’ offices may need to be contacted to get accurate patient medication information

• The Joint Commission (TJC) now has a National Patient Safety Goal (NPSG) that requires hospitals to reconcile patient medications at each step in the inpatient health care process– At intake, at transfer within and outside the facility, and at

discharge– Applies to inpatient and outpatient admissions– See www.jointcommission.org for up-to-date information

Identifying the Patient• Possibility of medications being administered to the wrong

patient can start in any phase of the medication-use process – Physician orders a medication for the wrong patient– Secretary or nurse transcribes the order onto the wrong patient’s

MAR– Pharmacist enters a medication into the wrong patient’s profile– Nurse gives a patient’s medication to another patient

• Reading the patient’s armband and as a spoken affirmation of the patient’s name are necessary (“What is your name?” and not “Is your name John Doe?”)

• In 2004, TJC began requiring use of two unique identifiers (e.g., name, birth date, identification number) when taking blood samples, or when administering medications or blood products

• Patient’s MAR should be taken to the beside for the required verification of patient identifiers– Point-of-care bar code systems, which scan the patient

identification bracelet and the drug for verification, help confirm accurate delivery

Monitoring the Patient• Nurses and caregivers must continually evaluate the

effects of medications on the patient to ensure safety and efficacy

• When trating patients with pain, both pain management and safety are high priority– Insufficient monitoring can lead to oversedation– Evaluate pain scores after each dose– Evaluate respiratory rate, depth, and quality – Consider cumulative narcotic dose (e.g., both intra- and post-

operative doses in post-anesthesia care unit [PCAU])

• When assessing need for a therapeutic change, consider therapeutic goal, patient input, and safety

• Lab and diagnostic results can guide medication selection and dose modification as well as signal that medication is contraindicated– Plotting dose administrations on a flow sheet along with key

laboratory values is a useful technique for monitoring medication therapy

Drug and Dosing Guidelines• Nurses need ready access to reliable information

– Typical dose and route of administration for a new medication recently added to the formulary

– IV compatibility– Typical doses, in milligrams per kilogram, for pediatric

patients – IV / PO dose conversion chart for opioids– Acceptable infusion rates for medications (e.g.,

heparin)– Whether a medication can be crushed for

administration

Drug and Dosing Guidelines• Nurses need access to current drug information references

– Books, electronic databases, textbook, or reliable Internet source– Must be up to date (discard outdated material)– Information needs include: incompatibilities, adverse events,

changes in drug administration policy, and addition of new products

• At a minimum, provide references for:– Drugs and herbals– Dosing guidelines

• Dosing charts

– Adverse drug reactions and drug interactions

Drug and Dosing Guidelines

• No more than two– Nurse should question a single dose composed of more than

two dosage units• Pharmacist can often formulate several tablets or capsules into a

single dose, making it easier for the patient to swallow• Same principle applies to preparation of IV solutions

• Change in dose with change in route– Because of potential differences in bioavailability and drug

distribution, verify the dose when route of administration is changed

• Examples: levothyroxine, opioid analgesics, and hydromorphone

Drug and Dosing Guidelines• Drugs expressed as a ratio or percentage

– Most injectable medications expressed in mg/mL or mcg/mL– Many drugs used for resuscitation expressed as

percentages or dilution ratios• Dose conversion chart for all concentrations of drugs used for

emergencies should be posted on code carts • If possible, have only one concentration available; bold warning

labels should be affixed to alert staff if different concentrations are available

• Liposomal products– Some medications available as conventional and liposomal

formulations; dosages are not interchangeable• Examples: Amphocin, Fungizone, and Adriamycin

– Store and dispense by the pharmacy only– Encourage physicians to include the brand name when

prescribing liposomal products• List both brand name and generic on MARs, as well as “liposomal

form”• Independent double check before administering is advisable

Communicating Drug Information Accurately

• Errors can originate in either of the two places nurses get information about the drugs they administer: – MAR– Original medication order

• Problems arise from these sources:• Order or prescription• Order transcription• MAR• Documenting administration• Communicating orders to the pharmacy• Communication barriers

The Order or PrescriptionWritten Orders

– Most medication orders are handwritten using lined no-carbon (NCR) order forms

– Lines on the order form help legibility, but may obscure part of the writing

• 7 may appear to be a 1 or a decimal point or other mark is not seen

• 0.5 mg may appear to be 5 mg if the physician fails to put the zero and the decimal is obscured on the line; 1.0 mg may appear to be 10 mg

– Eliminate the lines from the back copy of the NCR form to help prevent errors

• Add a zero before a decimal point and eliminate trailing zeros

– Only the original should be used to fax or scan

– Clinicians should not try to interpret marginally legible orders• When in doubt, call for clarification!

The Order or PrescriptionError-Prone Abbreviations• Poorly communicated drug information can lead to errors

– Error-prone dose expressions– Abbreviations– Acronyms– Coined names– Symbols– Use of incorrect drug names– Confusing expressions of dosage forms

• TJC forbids using certain ambiguous expressions and abbreviations (see Chapter 8 on error-prone abbreviations and dose expressions)

The Order or PrescriptionIncomplete Orders• Question any unclear or potentially ambiguous order before

administering a medication• Following package directions may not be the way a physician wants the

medication administered

Verbal Orders• Orders spoken aloud whether in person or over the phone, can easily be

misunderstood• Only the prescriber can verify that the recipient heard the message

correctly• Incomplete verbal orders may result in the nurse filling in presumed

information which may be incorrect

• Since 2003, TJC has required this procedure:

1) Nurse transcribes verbal order onto patient’s record as received

2) Nurse reads back (not repeats back) the complete transcribed order to the prescriber, repeating each digit in the dosage separately (e.g., five-zero rather than 50)

Order Transcription• Transcription of spoken or written orders can result in

errors• Using computerized prescriber order entry (CPOE)

eliminates traditional order transcription• Precautions providers should take when transcribing

spoken orders– Avoid numbered orders

• Order number may be misinterpreted as part of the dose

• If numbering is necessary, circle each digit so the number is not written as part of the dose

– Always list the dose after the drug name on transcribed orders, not before it

– Stray marks (e.g., initials, letters, or check marks) can obscure or change the look of a medication order

• Table 11-1 in the textbook addresses safety strategies for accepting and transcribing spoken orders

Order Transcription• Written orders received by pharmacists and nurses

should be uncluttered and clear• Necessary notations that are not part of the drug and

dosage should be made at the bottom of the page– Notations written on the bottom are less likely to obscure

the drug dose or drug name

• A separate column or box should be included on the form if notations or check marks are needed to track complete transcription within order sets

Medication Administration Records• MARs can be in several forms:

– Handwritten– Computer print-out– Displayed on an electronic screen

• Ways errors occur on handwritten MARs:– Writing is crowded or illegible– Information is presented in an inconsistent manner

• Orders are transcribed onto the MAR exactly as written– Presentation of information may not be consistent– Error-prone abbreviations or dose expressions may be carried

onto the MAR – Allergies and other information may not be present on a

handwritten MAR

• A medication prescribed and transcribed using brand name but dispensed as a generic may cause confusion

Medication Administration Records• Benefits of computer-generated MARs for preventing

errors– New, changed, or discontinued orders appear on the MAR in

“real time” awaiting verification by the pharmacist and nurse

– Brand and generic names of the product listed– Consistency (e.g., spelling, dose documentation)– Enables the nurse to compare his/her transcription with the

pharmacist’s– Provides consistent drug messages, warnings, and

information on patient allergies, current diagnoses, and chronic conditions

Medication Administration RecordsIdeally, MAR would list:– First line: drug name (generic with brand in parentheses)– Second line: patient-specific dose, route, and frequency

(and indication, if applicable) in bold print– Third line: product strength, special instructions, or

warnings

Medication Administration Records• If oral liquids must be dispensed in multidose bottles, the

container’s total volume should not be listed on the MAR• Interdisciplinary meetings to identify and prioritize MAR

format problems can help to ensure the presentation of medication orders is clear to nurses– Essential for information system staff to attend so they can work

with the software vendor to make changes

• MARs that are too long can lead to inadvertent omissions– Long MARs may be the result of preprinted order sheets – Medications need to be standardized among the various

preprinted order forms – All contingencies do not need to be covered on preprinted orders– MARs with too many pages need to be identified and addressed

• Clinicians can work on preprinted orders to minimize the variety of prescribed medications, routes of administration, and dosages

Documenting Administration• The medication must be recorded on the MAR

immediately after it has been administered, not before administration to patient– Recording too early and then not giving the medication could

result in patient receiving no medication– Recording patients’ doses later and not completing the task

could result in duplicate medication

• Dose administration documentation should be in a portion of the record designated only for that purpose– Do not document dose administration within the narrative

notes– Some drugs, like insulin, have extra space for recording

monitoring variables, however these records should not be kept separately in the chart because the MAR will be incomplete

– Alert prescribers when the patient refuses a dose – Follow-up should take place when an unadministered dose is

returned to the pharmacy with no explanation for the reason (although this is a good idea, it is often not feasible)

Communicating Orders to the PharmacyIf CPOE Is Not in Place

• A fax or scanned image is often sent to the pharmacy by unit secretaries

• The pharmacy staff may make regular rounds to the nursing units to pick up copies of the orders in some institutions

• Orders may be sent via pneumatic tube to the pharmacy

Send All Orders• All orders should be sent to the pharmacy• Pharmacists need to be aware of all information

regarding the patient:– Tests and procedures, dietary status, planned discharge

• Total record of the patient helps pharmacist critically assess each medication order

• Voice mail or other message systems are not appropriate to communicate orders because there is no reading back of the transcription

• A faxed copy of the actual order may be a safer method

Communicating Orders to the Pharmacy

Causes of Obscured or Illegible Transmissions• Roller of a fax or the glass surface of a scanner must be

cleaned regularly and well maintained when they are used to send medical orders or prescriptions

• Line noise during transmission, dust, dirt, stuck paper, correction fluid, and hole punches

• Stickers affixed but not removed before transmission• Prescribers sometimes write to the edge of the

document and the scanner or fax does not “read” the whole order causing part of it to be lost

• Figure 11-2 in the textbook shows an example of an order that was read incorrectly because of a poor image transmission

Communicating Orders to the PharmacyAdmissions From Emergency Department (ED)• Pharmacists may not be dispensing all medications

administered to patients in hospital EDs because the nurse does not send the order to the pharmacy for medications that are available as floor stock

• Staff must communicate all the drug therapy that has been prescribed and administered if the patient is admitted

• Profile should include drugs from the ED so drugs prescribed upon admission can be compared and screened against the medications used in the ED

• For updated requirements regarding ED dispensing and administering, see www.jointcommission.org

Communicating Orders to the PharmacyAdmissions From ED (continued)

• A particularly harmful duplicate therapy from the ED includes the use of heparin – Patients’ current and recent MARs should be reviewed before

any heparin product is administered to prevent unintended duplicate therapy

• Helpful reminders on the order forms and heparin protocols:– Discontinue low molecular weight heparin (LMWH)– List time interval (8 to 24 hours) before heparin therapy can

be started if a patient has received a dose of LMWH

• ED nurse should mention and clearly document all doses of LMWH administered when the patient is transferred to an inpatient setting

Communicating Orders to the PharmacyCommunication Barriers• The hierarchical structure in health care organizations may

make it uncomfortable or difficult for nurses and other health care professionals to share concerns or voice opinions about the safety of an order

• Review Chapter 23 in the textbook for strategies to overcome intimidation and improve communication for managing medication risks

Drug Labeling, Packaging, and Nomenclature

• Picking up a container and thinking it is a different product is easy to do because packaging is similar with some products

• Table 11-2 gives some safety strategies for look-alike and sound-alike drug names– Affix “name alert” stickers to areas where look-alike products

are stored– Accept spoken orders only when truly necessary– Circle important information on the package to draw attention

to differences– Segregate medications with look-alike packages by storing in

separate areas– Create alerts to appear on the screen of automated dispensing

cabinets (ADCs) for medications in look-alike packages

Additional Information on the

Role of Drug Names and

Drug Packaging and Labeling

in Medication Errors

Available in Slide Deck for

Chapters 6 and 7

Drug Labeling, Packaging, and Nomenclature

Syringes• Errors can occur when a nurse with an unlabeled syringe

intends to use it immediately but gets interrupted and puts it down unlabeled – A syringe of medication or solution must be labeled if it leaves the

hand of the person filling it and will not be administered immediately– A syringe prepared anywhere other than at the bedside for immediate

use must be labeled

• Use commercially prepared labels, restock labels often, and do not use tape to label syringes

Drug Labeling, Packaging, and Nomenclature

Medications on a Sterile Field• Findings of a 2000 self-assessment by participating

hospitals– 25% reported full labeling– 24% did not label anything

• Findings of 2004 ISMP Medication Safety Self Assessment (1,600 hospitals) – 41% reported always labeling containers used on a sterile field – 18% reported not labeling any solutions or medications on the sterile

field

• Only a slight improvement in this basic safety measure is surprising

• The requirement for labeling in inpatient and outpatient settings was the subject of an NPSG in 2006 by TJC see www.jointcommission for full details

Drug Labeling, Packaging, and Nomenclature

Labeling to the Point of Administration• Do not open or remove medications from unit dose packages

until the point of administration• Medications are difficult to identify once removed from

packaging– Unlabeled medications should not be returned – Increased risk of mixing up medications once the packaging is

removed

• Taking medications for multiple patients into a patient’s room increases the chance the a patient will get the wrong medication

Drug Storage and Standardization

Storing Drugs on Patient Care Units

• Safety checks are bypassed when products are available for administration prior to a pharmacist check (e.g., floor stock not in an ADC)

• Problems can occur when the pharmacist does not screen patient-specific doses before administration of the drug– Excessive doses, duplicate therapy, drug allergies not detected

Unit Dose Distribution

• Credentialing agencies such as TJC recognize unit dose distribution as the standard of practice for inpatient settings – Reduces the need for floor stock in patient care areas

• Many drugs are received in bulk and need to be repackaged

• Methods that reduce errors when repackaging should be employed

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Chemicals

– Some chemicals, (e.g., Hemoccult Sensa, Seracult) routinely by nurses have been mistaken for eye drops

– Never leave these types of products in bedside stands, medicine carts, patient bathrooms, or anywhere they could be mistaken for medications by nurses, patients, or family members

– Never pour chemicals used for any purpose into saline, medication, or water containers, even if labeled clearly

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Concentrated electrolytes

– Access to undiluted electrolytes should be restricted or eliminated– TJC requires the removal of concentrated electrolytes (e.g.,

potassium chloride) from patient care units because they have been mistakenly given without the proper dilution, resulting in death

– Similar dangers are still posed by other concentrated electrolyte solutions (e.g., sodium chloride >0.9%)

– Treatments for cases requiring electrolytes, such as severe hyponatremia, can be started with typical concentrations of sodium chloride until the needed concentration can be prepared by the pharmacy or the premixed solution can be dispensed

– Review chapter 14 in the textbook for additional cautionary information about electrolytes and other high-alert medications

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Concentrated morphine oral solution

– Available at both 20 mg/5mL and 20 mg/mL creating potential for confusion

– Some physicians prescribe in mL instead of mg, causing errors when multiple concentrations available

• Orders without a specified dose in mg should not be accepted

– Pharmacy should dispense concentrated oral morphine solutions in unit dose oral syringes for specific inpatients rather than having floor stock in patient care unit

– Unused supplies should be returned to the pharmacy immediately after the patient is discharged

– The wrong strength of concentrated product could be stocked or removed by mistake, therefore ADCs alone will not prevent errors

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Concentrated insulin

– Some patients with insulin resistance are prescribed concentrated insulin (500 units/mL or U-500) rather than U-100 insulin

– U-500 Humulin R has a red label that warns “high potency” and “not for ordinary use,” but the type size is small and easily overlooked

• Documented mix-ups include a nurse taking U-500 from the refrigerator and administering it as U-100, resulting in a fivefold overdose

• U-500 was on the patient care unit because it had been previously prescribed for a patient who had since been discharged

– Ideally, pharmacy should dispense the dose in a syringe when the insulin is prescribed for a specific patient

– U-500 should never be given IV because of the potential danger from an overdose

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Sterile water

– A lack of knowledge about the hazards of IV administration of sterile solution have resulted in serious patient harm and death

• Physician prescribed “free water” IV at 100 mL/hour for an elderly patient with congestive heart failure, hyperglycemia, and severe hypernatremia

• Free water is water not associated with organic or inorganic ions• Free water can be given orally but never by IV as plain sterile water

without additives to increase osmolarity• The physician had called the pharmacy and asked if large bags of

sterile water for injection were available and the answer was yes• The 2 L bag of sterile water was sent to the ICU after the order was

received and the nurse began the infusion without question because she had overheard the physician’s question to the pharmacy

• The nurse missed the red statement on the bag: “Pharmacy Bulk Package, Not for Direct Infusion” because the label was on the opposite side of the bag and another warning against using the product for IV injection without first being made approximately isotonic was obscure in text

• The error was caught by another nurse and the IV stopped, but the patient subsequently died of renal failure

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Sterile water (continued)

– Establishing a protocol for severe hypernatremia can avoid this type of error

– Pharmacists should use 2 L containers or larger of sterile water in the pharmacy for preparing solutions, making it more apparent to nurses if the larger bag was dispensed mistakenly

– Bags of sterile water have been mistaken for look-alike bags of IV solution when inadvertently stocked on patient care units

– The Malignant Hyperthermia Association recommends that 1 L bags of sterile water for use in diluting Dantrium be stocked in the hyperthermia boxes in ORs and PACUs

– Unused or partially used bags of the sterile water solution may get into IV stock or be hung as IV solution during emergencies causing a concern for hospitals

– Errors can be prevented by replacing 1 L sterile water bags with 50 mL vials

Drug Storage and StandardizationHazardous Drugs and Solutions in Floor Stock• Neuromuscular blocking agents

– Deaths reported when neuromuscular blocking agents were removed from the refrigerator and mistakenly administered to patients who were not mechanically ventilated; errors caused by:

• Similar packaging• An inexperienced nurse medicates an agitated patient with the agent that a

physician failed to discontinue after extubation

– These drugs should be stocked only in critical care units, the ED, and the OR

– Neuromuscular drugs should be stored in zip-lock bags with the following warning label affixed: “WARNING: Paralyzing agent”

– Neuromuscular drugs should be completely separated from other stock, preferably in a closed box in the refrigerator

Drug Storage and StandardizationMultidose Vials• The use of multidose vials (MDV) is a cost saving measure

that should be reexamined– Contamination of the MDV can quickly erode the cost-saving factor– Practitioners may decide that more of the solution is needed for the

patient, use the same needle and syringe, and contamination occurs– Single-dose vials of anesthetics contain no preservatives to

prevent microbial growth, therefore they should not be reused after initial entry

• Use prefilled syringes, either purchased or filled by the pharmacy, instead of vials for heparin flushes, saline, and bacteriostatic water– Pharmacy should dispense labeled vials for each individual

patient if MDV must be used– Keep the vial with the patient’s medications and discard

upon discharge– Store and discard MDVs according to manufacturers’

recommendations– MDVs that are used but undated should be discarded

Drug Storage and StandardizationFlammable Products• Each year about 100 surgical fires occur with outcomes that

can be devastating• Some of these fires are a result of flammable medications

in the form of ointments, wound dressings, skin preparation agents, and eye lubricants

• Flammable benzoin sprayed on an operative incision ignited when a physician decided to cauterize a bleed after he had nearly finished suturing an eye

• Highly flammable products, such as ethyl chloride, can be ignited with even a static discharge

• Often, safer alternatives are available; the need for the use of a flammable product should be evaluated

Drug Storage and StandardizationMissing Medications• A missing medication dose can be a sign of a potential

error– Medication was given but not documented– Medication was given in a procedure area or on another unit– Medication was ordered by brand name but dispensed as a generic – Therapeutic interchange occurred – Medication frequency or time was not correctly scheduled– Order was incorrectly interpreted or transcribed, or not sent to the

pharmacy – Pharmacy did not dispense the medication because of a safety

problem (e.g. unsafe dose)– A discontinued drug remains active on the MAR

• Missing doses could be related to system problems with pharmacy dispensing and delivery

• The original order should be verified before a missing medication is requested and administered

• Never borrow a dose from other patients’ supplies even if it causes a delay in treatment

Drug Storage and StandardizationNurse Preparation of IV Solutions• Procedures for preparing a drug infusion are:

– Assemble correct drug with correct volume and solution of diluent– Calculate and measure how much drug to add to the solution– Mix the solution and prepare an accurate label

• Work space is often cramped counter in the nursing unit, likely with distractions and interruptions during the process– No independent double-check system– Not conducive to safe drug preparation– Using pharmacy-prepared or commercially available admixtures is

much safer and simpler– Pharmacy should prepare and dispense injectable solutions not

commercially available• Rarely should a nurse mix and hang a solution immediately

– Another nurse should independently verify the calculations and preparation if pharmacy is closed or in emergency situation

Drug Storage and StandardizationNurse Access to Pharmacy• TJC does not allow nurses to have access to the

pharmacy; also some states prohibit after-hours access; for complete rules concerning after-hours access, go to www.jointcommission.org

• Many errors linked to nonpharmacists retrieving the wrong medication, dose, dosage form, strength, vial, or concentration from the pharmacy– A nursing supervisor opened a pharmacy and tried to

determine the contents of 15 mL vials of potassium phosphate injection

– The information on the label was overwhelming, but the supervisor believed that 15 mM and 15 mEq were equal, so she dispensed two vials that were mixed and added to the IV fluid of a patient by another nurse

– The supervisor documented two vials at 15 mM, but left a 15 mL vial as a sample; thus, the error was detected when the pharmacy reopened within the hour

Drug Storage and StandardizationNurse Access to Pharmacy (continued)• What to do when pharmacy services are not available:

– Use an outside pharmacy– Have floor stock in ADCs– Have floor stock in nonautomated dispensing cabinets– If state laws and regulations allow, give access to a location

containing selected medications– A night formulary with a limited supply of specific medications

could be stocked in a centralized dispensing cabinet• Stock with premixed IV solutions• Stock with unit dose medications• Nonformulary drugs should not be available• Minimize the number of vials or doses

• Night drug cabinet policies help prevent errors• Centralized order processing systems help prevent errors

Environment, Workflow, and Staffing PatternsDistractions• During 1998–2002, nearly 35,000 distraction-related

errors were report to USP’s MEDMARX database; nurses were the largest category of personnel involved in these errors– 11% of prescribing errors– 12% of administration errors– 73% of transcription errors

• Distractions doubled the rate of “wrong patient” errors• Nurses are subjected to many distractions that may interfere with

tasks involved with drug administration• Inadequate staffing for a given workload coupled with ringing

telephones and requests for information are common problems during transcription and entry of orders

• Poorly designed work processes contribute to the likelihood of errors

Environment, Workflow, and Staffing PatternsStaffing Level• A 2003 IOM report concluded that nurses work in an

environment that fosters errors, not safety• Medical-surgical nurses were found to be responsible for 6

patients daily with 23% of hospitals reporting as many as 12 patients

• Nurse staffing patterns should:– Provide elasticity in each shift to accommodate

unpredictable variations in patient volume, acuity, and workload

– Let nursing unit staff regulate unit workflow and determine criteria for unit closures as their workload and staff dictate

– Continually evaluate the effectiveness of staffing practices• ICUs should have one licensed nurse for every two patients • Long-stay residents in nursing homes should have:

– One RN for every 32 patients (0.75 hour per resident day)– One licensed nurse for every18 patients (1.3 hours per resident day)– One nursing assistant for every 8.5 patients (2.8 hours per resident day)

Environment, Workflow, and Staffing PatternsStaffing Level (continued)• Nursing home staffing regulations are not in line with

current safe staffing practices (e.g., regardless of patient capacity, requirement is one RN for 8 consecutive hours daily)– Most of the care in nursing homes is provided by nursing

assistants, with federal regulations specifying no minimum staffing levels

• The 2003 IOM report found that changes in nurse staffing patterns are needed to improve patient safety– Patient volume estimates should count admissions,

discharges, and less than full-day patients as well as patients at a point in time

– Direct care nursing staff should help select and evaluate the methods used to determine the appropriate unit staffing for each shift

Environment, Workflow, and Staffing Patterns

Long Hours and Overtime• Long work hours and fatigue of health care providers

pose serious threat to the safety of the patients• A health care provider who has been awake for 24

hours has the cognitive functioning of someone who is legally drunk

• According to the 2003 IOM report, nurses should work no more than 12 hours a day and 60 hours a week (including scheduled shifts and overtime)

• See Reducing Fatigue in the Workplace on page 267 of the textbook for further fatigue fighting recommendations

Environment, Workflow, and Staffing PatternsWorkflow and Workload• Timing of medication administration

– Usually within 60 minutes of the scheduled time is the defined time frame for medications to be administered

– Unit dose systems have improved the timeliness of administration because of the reduced preparation time

– More medications are administered in the morning than at other times, therefore the potential for error is greatest in the morning

– Medications such as warfarin are given in the late afternoon or at bedtime allowing for laboratory monitoring before administration

– Timing of each medication has to be considered in relation to other medications the patient is receiving

– Drug incompatibilities or interactions should be noted when the medications are ordered and added to the MAR

– Nurses and pharmacists should work together to determine the appropriate administration schedule

Environment, Workflow, and Staffing PatternsWorkflow and Workload (continued)• Standard administration schedules should be

determined by the facility– Delayed, omitted, or duplicate doses are a result of:

• Nonstandard times• Delayed therapy• Forgetting to administer the drug • Nurses not accustomed to administering drugs at

nonstandard times• Duplicate drug administeration (at the conventional time

and again at the nonstandard time)

• Dosing windows– Nurse needs an agreed-upon way to convert subsequent

doses to the standardized schedule when a first dose is given at a nonstandard time

– Many hospitals have guidelines for these “dosing windows”

Environment, Workflow, and Staffing Patterns

Workflow and Workload• Dosing windows

– This matrix of staggered dosing times provides a guideline for determining when to safely administer the second dose based on when the first does was administered

– By the third dose, patients are generally back on schedule– Dosing windows give consistent guidelines to both nurses

and pharmacists to help ensure that a schedule is followed– Exceptions have to be made for drugs that require

individualized pharmacy scheduling based on the time of the first dose

– Changes in schedules may result when a patient requires a procedure or to avoid simultaneous administration of incompatible drugs

– The dosing window matrix is a helpful way to keep communication open between pharmacists and nurses

Staff Competency and Education• All health care providers require education on a continuing

basis, whether they are new or seasoned veterans• Competency is improved by having timely access to

information about proper use of medications• Recommendations for nurses in the 2006 IOM report,

Preventing Medication Errors, include:– Make a safe work environment for medication preparation,

administration, and documentation– Commit to safety principles in medication administration– Question drug orders and evaluate patient responses

confidently with improved team training and communication – Strive to improve the systems that address near misses– Help to evaluate the efficacy of new safety systems and

technology– Contribute to development and implementation of error

reporting systems and support the reporting of medication errors

Patient Education• Errors can be prevented when patients are encouraged

to ask questions and get answers about their medications

• 2003 ISMP survey of nurses on teaching patients about their medications – 94% most often talked to their patients at discharge– 84% most often talked to their patients during drug

administration– One-quarter never provide written information

• One-third felt the written material did not provide clear information

• One-quarter said lack of written materials about medications was a frequent problem

• One-third said multilingual material access was difficult• One-quarter found the materials were not written on a level

their patients could easily understand because of reading level or health literacy

Patient Education• 2003 ISMP survey of nurses on teaching patients

about their medications (continued)―68% require all patients to repeat information or

demonstrate techniques they were taught– 75% in teaching hospitals required repeating of

information or demonstration of techniques– 80% gave patients a way to contact them with

questions after discharge– 56% in teaching hospitals had little or no written

information to give patients about prevention of medication errors

– 41% in nonteaching hospitals had little or no written information to give to patients about prevention of medication errors

– Table 11-5 in the textbook gives tips for teaching patients about using their medications

Quality Processes and Risk Management• Unlike prescribing errors that may be intercepted by

the pharmacist or nurse, medication errors originating during the medication administration process are likely to reach the patient

• More than 50% of the medications that cause harm begin with drug administration

• Double-check systems for medication administration are necessary to prevent potentially harmful errors by detection and correction before the patient receives the drug– Interdisciplinary double-check system– Independent double checks– Automated double-check systems

Interdisciplinary Double-Check Systems

• Having more than one practitioner between the drug and the patient is the ideal medication administration system– A pharmacist may find a prescribing order that includes an

inappropriate dose, duplicate therapy, or drug interaction– A nurse may find a pharmacy dispensing error while

checking before administration– A physician may be checking the daily printout of the

patient’s current medications and find a drug has been discontinued inadvertently by a nurse or the pharmacy

• A system for double-checking medications is present in most pharmacies

• Safety is compromised when drugs are borrowed from other patients, obtained from the ADC prior to pharmacists’ screening, or prepared by nurses from floor stock

Interdisciplinary Double-Check Systems

• Unit dose system is utilized in most hospitals• Nurse and pharmacist can separately verify each dose

before it is sent to the unit or administered• The pharmacist checks the MAR, finds the dose does

not correspond, and is alerted to some error– Misinterpretation or mistranscription– Incorrect medication may have been chosen

• Examples showing utility of double checking– A float nurse misread the MAR, prepared a PHENobarbital IV

not in the bin, and administered the drug, never calling the pharmacy

• The dose was not missing, the patient was supposed to receive PENTobarbital and the pharmacist could have clarified

– An order for Rocephin was misinterpreted by the unit secretary and not questioned by the nurse; the order was put in as qid rather than q12

• The pharmacist caught the error or the patient would have gotten twice the amount of prescribed medication

Independent Double Checks

• Two nurses working separately can independently verify each other’s work, thereby creating a suitable double check– One prepares the dose while another independently checks the

order, makes calculations, and they compare– KEY = working separately, not encouraging and helping each

other to the same outcome– Person requesting the double check should not influence the

checker

• Nurses double checking is not always accepted because:– The time is not justified for the small benefit– More mistakes happen because the checkers rely on each other– Staff shortages; even with double checks errors can still happen

• Errors occur if illegible orders are misread by both nurses• Limit double checks to high-alert drugs, complex

processes, and high-risk patients• A process that prevents errors is better than one that

detects them

Automated Double-Check Systems

• Bar code scanning at the point of care is useful for verification

• Bar coding cannot yet confirm the correct programming of an infusion pump– This technology is in the pipeline and being tested currently

• “Smart” infusion pumps incorporate safe dosage ranges and accurate programming

• Smart pumps cannot verify the correct connections on the pump

• Keep manual checks for the most critical areas and work to design effective double-check systems

Reference

Smetzer JL, Cohen MR. Preventing drug administration errors. In: Cohen MR, ed. Medication Errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007.