medication errors

Copyright © 2011 F.A. Davis Company

Davis’s Drug Guide for Nurses, 12th EditionDavis’s Drug Guide for Nurses, 12th Edition

Medication ErrorsMedication Errors

Improving Practices and

Patient Safety



Medication ErrorMedication Error

A preventable event that leads to inappropriate medication use or patient harm.



Causes of Medication ErrorsCauses of Medication Errors

NOT the result of poor-quality staff!

Error-prone processes involved in the medication use system contribute to medication errors

Excellent, experienced practitioners make mistakes



Medication ErrorsMedication Errors

Most medication errors do not result in patient harm

Some medication errors result in catastrophic harm or death

High risk with High Alert Drugs — highly toxic drugs or drugs with a narrow therapeutic range have a high risk of causing devastating injury or death; see Davis’s Drug Guide for Nurses for a list of high alert drugs



Selected Elements of the Medication Selected Elements of the Medication Use SystemUse System

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

timing, programming of infusion devices, etc.) Monitoring drug levels and therapeutic or

nontherapeutic responses Thorough patient education



Communication ProblemsCommunication 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



Misuse of Zeroes: “Lead Don’t Trail”Misuse of Zeroes: “Lead Don’t 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 factor of 10



Error-Prone Abbreviations 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, especially if there is insufficient space between number and letter: 10u hand or computer-entered can look like 100

See Davis’s Drug Guide for Nurses for a table of error-prone abbreviations and safer alternatives



Poorly Written Orders Poorly Written Orders

Quickly, sloppily written orders historically have been a source of medication errors

Even orders viewed on a computer screen or printed out can be misread

Some orders lack important elements

If you have to ask yourself what the order means, ask the original prescriber, too!



Sound-Alike, Look-Alike DrugsSound-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!



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

wrong product could be picked up inadvertently

TALL MAN lettering helps prevent such confusion by highlighting certain syllables for especially problematic drug pairs

Example: acetoHEXAMIDE and acetoZOLAMIDE

See Davis’s Drug Guide for Nurses for a list of drugs requiring Tall Man lettering



Dose MiscalculationsDose Miscalculations

Major cause of medication errors

Can be a mathematical error or a failure to consider patient’s age; renal or hepatic function; or other modifying factor

Includes miscalculation of dosage or rate of administration and misprogramming of infusion pumps



Incorrect Drug AdministrationIncorrect Drug Administration

Don’t forget the 5 Rights

Right drug

Right patient

Right dose

Right route

Right time



Human and Environmental Factors Human and Environmental Factors That Influence ErrorsThat Influence Errors

Distractions

Poor staffing

Culture of perfection

Questioning physicians is tacitly discouraged

Punitive response to error (“shame and blame”)



Prevention Strategies for NursesPrevention Strategies for Nurses

Clarify any order that is not obviously and clearly legible

Do not accept orders with the abbreviation “u,” “U,” or “IU” for units

Clarify abbreviated drug names or dosing frequencies



Prevention Strategies for Nurses (Cont’d)Prevention Strategies for Nurses (Cont’d) If dose requires >3 or <1/2 of a dosing unit

(e.g., ampoules or tablet), have another healthcare provider check the original order and recalculate dose

ALWAYS confirm unusual dosages with the provider

Refer to a third source, such as your Davis’s Drug Guide or a pharmacist



Prevention Strategies for Nurses (Cont’d)Prevention Strategies for Nurses (Cont’d) 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 the nurse's/clerk's transcription against the original order; make sure stray marks or initials do not obscure the original order



Prevention Strategies for Nurses (Cont’d)Prevention Strategies for Nurses (Cont’d)

Do not start a patient on a new medication by borrowing medications from another patient

Doing so bypasses the double check provided by the pharmacist’s review of the order




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




Be sure to fully understand any drug administration device before using it

This includes infusion pumps, inhalers, and transdermal patches

Have a second practitioner independently check original order, dosage calculations, and infusion pump settings for high alert medications



Preventing Med Errors in the HomePreventing 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 Davis’s Drug Guide for Nurses for more information about patient education



Reporting Medication ErrorsReporting 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 online https://www.accessdata.fda.gov/scripts/medwatch/

Or by phone: 1-800-FDA-1088

medication errors

Health & Medicine

medication errors excellent

source of medication

inappropriate medication

drug levels

written orders

death seedaviss drug

list of drugs

abbreviated drug names