-
8/12/2019 Medication Errors Improving Practices and Patient Safety
1/22
Copyright 2011 F.A. Davis Company
Daviss Drug Guide for Nurses, 12th Edition
Medication Errors
Improving Practices and
Patient Safety
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
2/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Medication Error
A preventable event that leads to
inappropriate medication use or patientharm.
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
3/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
4/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
5/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
6/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
7/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
8/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
9/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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!
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
10/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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!
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
11/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
12/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
13/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Incorrect Drug Administration
Dont forget the 5 Rights
Right drug
Right patient
Right dose
Right route
Right time
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
14/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Human and Environmental FactorsThat Influence Errors
Distractions
Poor staffing
Culture of perfection
Questioning physicians is tacitly discouraged
Punitive response to error (shame andblame)
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
15/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
16/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Prevention Strategies for Nurses (Contd)
If dose requires >3 or
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
17/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Prevention Strategies for Nurses (Contd)
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
18/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Prevention Strategies for Nurses (Contd)
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
19/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Prevention Strategies for Nurses (Contd)
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
20/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
Prevention Strategies for Nurses (Contd)
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
21/22
Daviss Drug Guide for Nurses, 12th Edition
Copyright 2011 F.A. Davis Company
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
D G id
-
8/12/2019 Medication Errors Improving Practices and Patient Safety
22/22
Daviss Drug Guide for Nurses, 12th Edition
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