Medication ErrorsCourse #109

2 contact hoursAuthor: Monica Oram, RN, BSN

This is NOT the Florida Required course.(The Florida Required Course is #104, preventing medical errors)

Upon completion of this course the reader will be able to achieve the following objectives: 1. Define what are medication errors2. Recognize high alert medications3. Understand importance of reporting errors4. Factors that contribute to medication errors5. Understand the five rights of medication administration

What are medication errors?

Medication errors are mistakes in the administration of drugs to patients.Medication errors can have serious results for our patients. Medication errors can cause pain and suffering, treatment delays, loss of income, and higher medical bills.

Healthcare workers are also affected. It is an experience that can cause guilt, anxiety and self-doubt.

Most medication errors can be easily avoided by double checking and being very careful as medications are administered.

You can reduce medication errors by making certain: You can read the doctor’s orders You check the drug against the medication administration record Make certain you are giving it to the right patient Always question any dose that seems too high or too low.

Your efforts will lead to greater patient satisfaction, and greater patient safety. You will experience greater job satisfaction by knowing you are practicing safely and efficiently.

Medication errors can occur:

1. When orders are not taken off properly, and carried out correctly.2. Orders are incorrect.3. Orders are not carried out at all.4. Orders are unclear.

Lets take a deeper looker….. When orders are not taken off properly, there can be many problems associated with medication errors. Many drugs look alike in name, or sound similar to others with a completely different purpose and effect.Errors can occur if a ward clerk takes off medication orders. Make certain that a nurse is double checking all orders against the physician orders to prevent a transcription error. If you are ever in doubt….check it out !!!

Incorrect orders can include ordering the wrong drug, or the wrong dose.This can also be a particular problem if the person has a known allergy, and it is not noticed before the drug is ordered or given.

When an order is not carried out, this is a medication error. Orders that “fall through the cracks” can be a serious problem to the patient in need of the medication. Unclear orders are a big problem that causes a lot of confusion. Confusion over what the order says often results in giving the wrong drug, or the wrong dose.

All medication errors should be reported.All medication errors should be taken seriously!

When orders are not carried out properly, this also creates a medication error, such as giving the right drug to the right patient, but giving it at the wrong time.

Suggestions To Prevent Errors

Beware of look alike and sound alike drugs- match the drug’s indications with the patient’s diagnosis to prevent this common occurrence.

One of the biggest liabilities and challenges for nurses is that we have a license to protect. One of the big problems is that the physician orders the

medication, the pharmacy fills the prescription, and the nurse administers the drug.

Why is this a problem?

This is a problem because there are several opportunities for an error to occur. The error can begin with the doctor prescribing the drug, or the pharmacy can make a mistake in filling the prescription. But it does not stop there…..The next liability falls on the nurse. Nurses have a lot of responsibility in ensuring that medications are given correctly. If a patient has a reaction, the nurse can be held liable because “they are the one who gave the medication”. Don’t be mislead that all nurses are held liable for all errors. This is not really the case. Doctors can and do face liability as well when wrong medications are ordered. Pharmacies are also to blame at times for errors. The point is, that nurses must be mindful to what is being administered. Nurses should know to check out anything that does not seem right. Nurses should be aware of the complications associated with potential adverse reactions from drug interactions. So, if the doctor prescribed the drug correctly, and the pharmacy filled the prescription properly, and the nurse gives the medication which in turn causes harm to the patient, then the nurse can be held liable for this error.

Nurses are most likely to be blamed for medication errors because they are involved at the administration level. Remember that medication errors are complex and are rarely ever the result of one person’s actions.

Statistical data suggests that when medication errors occur they can be broken down as follows:

35% of errors occur in the prescribing phase.45% of errors occur in the nurse administration phase.20% of errors occur in the pharmacy dispensing phase.Nurses today are faced with a tremendous amount of added responsibility, increased patient loads, and lack of sufficient staffing.With the increased workload and responsibilities, there are increased opportunity and chances for more medication errors to be made. Verbal orders a very high source of errors. When a nurse takes a verbal order, it is increasingly possible to interpret the wrong drug or dosage, making the liability greater on the nurse who “heard wrong” or “wrote it

wrong” as an order. Of the 45% of errors made by nurses, approximately 20% of these are due to verbal orders being taken incorrectly.

Suggestions To Help Avoid Errors

Beware of look alike drugs and sound alike drugs Match the drugs indication with the patient’s diagnosis Maintain competency in drug delivery devices. No delivery device is

safe unless the nurse can use it safely and properly. Use a system of double checks. Check concentration, flow rates, and drug

to be given. Organize the workflow- working in a cluttered place, poor lighting, noise

and interruptions make the preparation tasks more difficult and error-prone. (we all know that in the real world, these are a common occurrence and cannot be avoidable a lot of the time) Therefore, we have to know how to work in an environment that is conducive to providing safe patient care despite the environmental factors that are distracting)

Educate the patients- encourage them to ask questions. Listen to your patient- sometimes they can be the last line of defense to

avoid an error. Many are very aware of what medications they are receiving. Let’s look a few examples: If a patient says something like, “ I have not taken a pill that looks like this before” or “ I usually get only two pills in the morning” (and you have more than two in the medication cup) DO NOT GIVE THEM THE MEDICATION until you go back and check it out. They may in fact be right, and avoid a potential error before it occurs.

Healthcare professionals should remain educated and up to date on new medications. Invest in a good drug book and have it accessible on the job. Nurses are not doctors, and we are not pharmacists. We can’t be a “walking PDR”, but we can be educated and knowledgeable to look up what we don’t know.

Promote error detection and correction to uncover a problem before it reaches the patient. Honest reporting of errors helps all health care professionals to devise changes in the system that are a potential problem.

COMMON CAUSES OF MEDICATION ERRORS

Table Provided By Dana, 2001 and Fagan 2001Cause Description ExampleLack of knowledge of the drug

The nurse has insufficient knowledge of the indications for use, available forms, correct dose, appropriate routes, adverse effects, toxicity, and compatibilities of the medication

Rapid infusion of vancomyacin causing a hypotensive episode

Lack of information about the patient

The nurse is unaware of a vital aspect of the patient’s condition

Administering insulin without knowing the patient’s blood sugar

Forgetting and memory lapses

Errors in which the nurse knew the rules and is not able to explain the error

Missed doses of medication or duplicate doses of medications

Transcription errors Errors in the ordering or verification process

Writing 50 units of insulin vs. 5 units because the “u” looked like a zero

Faulty interaction with other services

Problems communicating with others when transferring between services

Changes in Vancomyacin dose (related to peak and trough) not reported to a nurse

Faulty drug identity Errors in identifying the drug that results in patient getting the wrong medication

Confusion with drugs that sound alike. Celebrex Vs. Celexa

Faulty dose verification Failure to ensure that the proper dose was given or dispensed

Hanging the same IV twice in a row, when two different IV medications were ordered alternately

Infusion pump and delivery system failures

Errors in setting up the infusion pump, confusion between central and peripheral lines, accidental tubing disconnections

Infusion of TPN through a peripheral line instead of central line. Overdose of medication from pump not set correctly

Inadequate monitoring Failure to appropriately adjust the dose of medication because of necessary monitoring. ( lab values, vital signs) not done or ignored

Physician not notified of critical lab values such as prothrombin time for a patient receiving coumadin

Drug stocking and delivery problems

Late or missing deliveries of medication to the patient

Medications or IV meds not delivered in a timely manner

Preparation Error Errors in calculating and mixing drugs that result in incorrect dose

Incorrectly prepared mixed insulin dose

Lack of standardization Administration errors resulting from non-standard concentrations, dosing schedules, or infusion rates.

Heparin for IV flushes available in 1,000 units/ml and 10,000 units/ml

Other Things To Consider

Abbreviations: When using abbreviations, stick to the standard

abbreviations that all are familiar with. Illegible or confusing handwriting and communication failure often contribute to errors involving abbreviations.

Examples of some problem abbreviations include: Handwriting a “u” for units. It can be mistaken for a zero.

Handwriting “g” instead of mcg. The “ “ can be mistaken for am M, and could be incorrectly interpreted at mg instead of mcg.

Watch for leading decimals and trailing zeros. The use of trailing zeros such as 2.0 instead of 2, or the use of a leading decimal point, as in .2 instead of 0.2 are very dangerous practices. It is easy for a nurse to miss the decimal point and make an error that is TEN TIMES incorrect.

Remember that “covering up” an error is unacceptable. You put your patient, yourself , your license, and your organization on the line when reporting of errors are not done.

Adverse event and error reporting is the professional and ethical responsibility of the nurse. Reporting “near misses”, even though no actual harm was done, is also very important to report.

In the past, healthcare professionals have used the personal approach of: “ Aim, Blame, Shame, and Retrain” That approach is not working. This is why the requirement of medical errors training has come about. We can learn from mistakes. A whole new approach is needed to not blame the individual making the error, but to look at systems that will improve and prevent the error from reoccurring.

The Five Rights

We all remember “the five rights” from nursing school. However, they are always worthwhile to review.

1. The right drug- read and reread the medication order and the drug label. When your facility changes drug vendors, take time to get familiar with the new labeling and markings. Be cautious of drugs that look alike and sound alike. When taking verbal orders, ask the physician to spell out the

name of the drug. Some manufacturers have even changed the names of drugs to prevent confusion. (Example: Losec to Prilosec, so as to not confuse it with Lasix)

2. The right patient- Be careful of name alerts, or patients in the same room with same first name or similar last name. Place name alert stickers on charts and MAR’s as needed. Identify patient by name band if unfamiliar with the patient. Confused patients may answer to any name. Example: Do not ask a patient, “ Is your name ____?” (a confused patient may say “yes” with no comprehension to who they are.) Pictures are helpful in LTC facilities. They need to be updated periodically though, because as they become sicker, gain weight or loose weight, the picture may no longer resemble the resident. These concepts are a particular concern if you work for a staffing agency, or if your facility utilizes agency nurses unfamiliar with the patients.

3. The right dose- The use of decimals and trailing Zeros, (as discussed earlier.) Take into consideration weight and age when deciding if dose is appropriate and should be in question. If ever in doubt, call the doctor. Clarify any order that is unclear. If you have to make a drug calculation, ALWAYS have a second nurse double check your calculation. Get familiar with the normal doses of medications and invest in a good drug book.

4. The right route- If the route is not specified, never assume it is oral.. It must be clarified. If a patient’s condition warrants a new route (ie: can no longer swallow pills, and requires liquid form) a new order must be written to reflect the change. If a liquid is used in place of oral, do not put in a syringe that could be mistaken for IV route. Spell out “intravenous” and “international units” so there is no confusion to IV&IU. Make sure all lines are labeled and dedicated for their purpose.

5. The right time- Medications should be given on time. Medication should not be given any more than one hour before or one hour after the scheduled time. The right time should be scheduled around manufacturer’s recommendations of with food or on an empty stomach. If a medication cannot be given on time, document why.

In addition, the patient has the RIGHT TO BE EDUCATED and the RIGHT TO REFUSE.

Right to be educated- Inform the patient what the medication is for and potential side effects to be aware of that may need to be reported.

Right to refuse- This is not a medication error, but does need to be documented as a refusal on the MAR. It should be documented in the medical record as well. Remember that if a patient refuses, it is not an error… but if the nurse leaves it at the bedside, and the patient throws it away, then it is a medication error.

MEDICATION CHECKLIST

BEFORE Patient’s name band checked or patient identified before given? Medication checked against MAR before giving? Medication is right route? Drug/drug and drug/food allergies observed? Medication prepared immediately prior to administration? Pulse or blood pressure checked if indicated? Privacy respected (drapes with NGT, g-tube) Nurse aware of reason for med?DURING Medication correctly crushed or not crushed as directed, if needed? Calibrated measuring devices when needed? Liquids measured at eye level? Medication diluted if indicated? NGT or G-Tube flushed before and after administration? Liquids shaken? ( unless contraindicated) Oral inhaler used properly? Tablets or capsules not touched by hands while preparing? Medication given within one hour of scheduled time? Medication given with milk, water or antacid if indicated?

Practice the “Three Time Check”

Read the label when you first get the medicationRead the label when preparing the medicationRead the label just before giving the medication

If you make a mistake

ACCEPT RESPONSIBILITYReport any error to your supervisor. Take steps to correct the situation right away.

HELP DETERMINE THE CAUSEThis helps improve medication policies and procedures, and helps reduce future errors.

FORGIVE YOURSELFNo one is perfect. Most healthcare professionals have had at least one experience with a medication error.

Help educate the larger medical community.

There is an anonymous hotline, where errors can be reported to help health care professionals, drug manufacturers and others to learn from mistakes.

You can report to the USP Medication Errors Reporting Program, operatedin cooperation with ISMP ( Institute for Safe Medication Practices) Reportsare made and retained in confidence, and used for statistical data and error research. www.ismp.org

Summary

Medication errors can be prevented if we take the added necessary steps to be more mindful of what we are doing. Those few extra minutes, that “we don’t have” can save a patient a lot of grief and/or potential harm or even death. Remember, “If in doubt, check it out.” Practice safe, and practice Smart. The rewards will go along way in protecting your patients, and protecting your self from liability. Your efforts help ensure that patients get the medications they need--- safely!References:

Mosby Drug Reference, 2003 Philadelphia, Pa.

Springhouse Nursing Manual

2002, Springhouse, Pennsylvania

Institute for Safe Medication Practices1-800-23-ERRORwww.imsp.org

Nurses' Six Rights for Safe Medication Administration

By Michelle Colleran Cook

Below, is testimony provided by MNA Member Michelle Colleran Cook on behalf of the MNA Congress

on Nursing Practice at a hearing before the Joint Committee on Health Care, which concerned the

issue of prevention of medication errors in health care settings.

My name is Michelle Colleran Cook. I am employed per diem in the Recovery Room of a Boston

teaching hospital. I am also an instructor in a LPN School of Nursing and will graduate from Regis

College with a Masters Degree in Nursing Administration in May 1999.

Recently, there have been national and local incidences of nurse errors in medication administration

that have resulted in negative patient outcomes. Nurses, because they administer the drugs directly

to patients, are the last links in the safe medication administration chain. Complicating matters is

the increased acuity of the patients they serve, and the decrease in the resources available to

nurses to ensure safe practice. Because of the climate of health care today, nurses need to become

cognizant of their practice’s vulnerability and vigilant about protecting their practice.

All nurses have been taught the five rights of medication administration. They were drilled into our

conscious in nursing school until they became part of our unconscious behavior as practicing nurses.

The right patient, the right drug, the right dose, the right route and the right time form the

foundation from which nurses practice safely when administrating medications to our patients in all

health care settings.

Just as nurses know the five rights of medication administration, they should also know what rights

they have when administering medications. These "Six Rights for Nurses Administering Medications"

will hopefully guide nurses as they continue to care for patients despite these turbulent times.

1. THE RIGHT TO A COMPLETE AND CLEARLY WRITTEN ORDER

You, as the nurse, have the right to demand that an order be complete and clearly written.

You have the right to require that the drug, dose, route and frequency be written by the

physician. All of these components must be present for a physician order to be considered

complete.

It is no longer good practice to accept orders when the dosage is written as "1 tablet." A

complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets

po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe

practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be

specific and the dose explicit.

Verbal orders should never be taken and telephone orders should only be taken if the

physician is not physically present. Nurses cognitively know this but often in the interest of

saving time may be tempted not to practice it. Nurses who write orders for physicians are

placing their license and their patients at risk.

Orders should be legibly written. The Massachusetts Hospital Coalition recommends

physicians use computers to directly order medications. However, such costly systems may

take years to implement. Until that occurs, nurses need to remember that it is their duty

and right to question physician orders that are illegible. Cefoxitan and Cefotetan may look

alike when hand written but confusing one drug for the other results in the patient receiving

the wrong medication.

 

2. THE RIGHT TO HAVE THE CORRECT DRUG ROUTE AND DOSE DISPENSED

Nurses administer medications but it is the pharmacy’s duty to dispense medications

correctly. Pharmacies process and distribute an incredible volume of medications daily.

Pharmacists, like nurses, are susceptible to the pressures of time and patient needs and can

dispense the incorrect drug or dose. The nurse who discovers the error then notifies the

pharmacy of this oversight. If all goes well, pharmacy will deliver the medication promptly

to the nursing unit. In this case the system works well.

Sometimes, the nurse is told there is no one from pharmacy available to deliver the

medication. The nurse is given the option of either waiting for her patient’s medication,

coming to the pharmacy herself to get the medication, or finding someone else to do so.

Such errors of dispensing eat away at nursing time and energy. They pull nurses away from

caring for their patients. They place patients in jeopardy of not receiving the drug on time.

Additionally, unnecessary stress is placed on the nurse who is struggling just trying to

gather the drugs necessary to care for her patient. This hurried atmosphere places the

nurse in a position that she may make a medication error in her haste.

Another recommendation from the Massachusetts Hospital Coalition states that a unit dose

system of medication can decrease the number of medication errors. Many hospitals have

adopted this system of medication administration. However, scenarios such as the one

above coupled with the available technology of automated medication administration

systems such as the Pixis has placed nurses in a potentially unsafe situation. First

developed to dispense narcotics, these automated systems can be programmed to allow

nurses access to many other types of medications. Now, in an attempt to address missing or

incorrectly dispensed medications, and decrease the turnaround time of getting the correct

drug to the patient, they are being used widely in acute care hospitals as quasi satellite

pharmacies.

At first, they may be seen by the nurse as a welcome relief from the frustration of not

having medications readily available to administer. But they must be used with caution. The

nurse enters patient data into the automated medication dispenser; the machine opens the

correct drawer and directs the nurse to the correct drug compartment where the medication

can be found. But in some systems, when the Pixis drawer opens, the nurse has access to

many drugs. In this situation, the unit dose safeguard is eliminated and therefore increases

the chances of the nurse selecting the incorrect drug or dose and administering it to their

patient.

3. THE RIGHT TO HAVE ACCESS TO INFORMATION

Nurses have the right to expect updated and easily accessible drug information. This means

that the hospital formulary, a Physicians Desk Reference and a current nursing drug

reference book need to be available to nurses who administer medications.

Nurses have the right to ask questions about the drugs that they are to administer to their

patients. Pharmacists are the drug experts and nurses should have access to a pharmacist

no matter what time of day. Hospitals need to have a pharmacist available on a 24-hour

basis. More dialogue between nurses and pharmacists can only improves patient outcomes

and decreases the chances of medication errors occurring.

As pharmacology and technology advances, patients should be able to expect a nurse who

is continually updated on new medications and the ways they are delivered. Good nursing

practice dictates that nurses are never to administer a drug they are unfamiliar with. If a

patient is to receive a drug that is too new to be in the usual reference books, nurses should

insist that information be provided to them. And they should not administer that drug until

they have enough information to be comfortable doing so.

 

4. THE RIGHT TO HAVE POLICIES ON MEDICATION ADMINISTRATION

It is the responsibility of health care administration to provide the structure necessary for

nurses to administer medications safely. Nursing practice is governed by the Board of

Regulation in Nursing but nursing policies are what guide nursing practice at that health

care entity. Policies often protect the nurse from litigation should an error occur.

Conversely, not following policy or administrating medication without a policy will put the

nurse at risk not only for litigation but can result in license suspension or forfeit.

New medications enter the market daily. Research discovers new uses and ways to

administer old medications. Administrators are not practitioners; they need to be updated

by staff on new trends in medication administration. Subsequently, nursing administrators

need to initiate and develop systems that promote safe medication administration. Nursing

administrators have to insist that nurses of their organization be allowed to deliver patient

care in the safest environment possible.

 

5. THE RIGHT TO ADMINSTER MEDICATIONS SAFELY AND TO IDENTIFY PROBLEMS IN

THE SYSTEM

Nurses are the experts on what impacts safe medication administration. Shaping systems

and creating solution for safe medication administration should include those who actually

do the work of administering medications.

Nurses have the right to speak up when they see situations that can potentially result in

medication errors. System glitches that place the patient at risk need to be addressed and

corrected. Repeated breaks in the system can only be fixed if at first it is identified. Just as

you would advocate for a patient, you should advocate for your ability to practice in a safe

setting. Your input is of tremendous value to all.

6. THE RIGHT TO STOP, THINK, AND BE VIGILANT WHEN ADMINISTERING

MEDICATIONS

Nurses know medication administration is serious business. Often nurses are caught up in

the hustle and hassle of a busy work place. With decreases in licensed staff and

organizational support and increasing patient acuity, nurses still manage to do it all. But we

are human, we are all fallible. There is only so much sensory input a person can handle,

only so many questions one can process at a time.

When we find our minds so overloaded we are unable to think. We have the right to stop

and do so. When we see orders that somehow do not make sense even if we can not

identify why this order seems odd, we have the right to stop and find out why. When we are

about to administer a drug we are unfamiliar with, we have the right to stop and find out

about this new drug. If we need to ask other nurses or professionals about this drug or

check the policy for giving this drug, we need to stop and do so. Will this take additional

time? Yes. Will others think we are stupid? Maybe. Will some people become irritated with

us? Probably.

But, if stopping to think before administering medications to your patient seems like an

inconvenience, ask yourself this question: Would I rather be known as the nurse who is slow

giving her meds, or the nurse who did her patient harm?

Unsafe medication administration situations will be lessened as long as nurses continue to

recognize problems and steadfastly protect their patients and their practice. Nurses need to

take the time to identify and address sloppiness in their work place and in other

professionals. Confrontation is not easy for nurses. Nurses would rather fix it themselves.

This system only perpetuates others’ poor practice and allows the nurse to assume

responsibility for all. This is not our job. Our allegiance is to our patients.

 

Course DescriptionPractical application of knowledge and skills required for nursing care of adult patients with commonly occurring acute/critical medical-surgical problems is demonstrated in both Lab and clinical settings. Concurrent enrollment in NSG 320 is required unless approved by the Department Chair. Clinical Lab is graded on a Satisfactory/Unsatisfactory basis based on successful completion of the course requirements.

Learning Outcomes Provide standardized nursing care to a group of adult, acutely/critically ill patients in a

structured setting. Perform nursing skills safely and effectively. Administer nursing care

based on the patient's present bio-psycho-social-cultural-spiritual situation. Determine the

patient's priority of needs and plan care accordingly. Complete nursing care for at least three

adult patients on time using an organized and efficient approach.

Utilize the nursing process to administer care to the adult patient with commonly

occurring health care needs and problems. Collect data on the patient's health status in a

systematic and objective manner using the system's review. Assess the data considering

the normal physiologic and psychologic parameters of the adult, acutely/critically ill patient's

experience and identify the assets and deficits of that experience. Formulate a nursing

diagnosis for each actual or potential problem which has been identified from the patient's

health assessment. Devise a nursing care plan which provides nursing interventions to the

patient as needed and reflects awareness of the priority problems in the care of the patient.

Implement the plan of care and state the rationale for the nursing interventions. Evaluate the

effectiveness of the care based on the stated expected outcomes or goals of care.

Provide appropriate health information to the patient and family using standardized

teaching plans. Assess the patient as to their learning needs and knowledge deficits.

Implement a standard teaching plan to meet the patient's learning needs. Evaluate the

effectiveness of that experience. Identify hospital as well as community resources available

to patients and make referrals following consultation with team leader or instructor.

Utilize therapeutic communication skills, guidance and support in interacting with the

adult patient and family and record observations in proper sequence and format. Recognize

own values and behavioral responses which may be conditioned by own culture and

experiential background. Provide therapeutic and supportive communication to the adult,

acutely/critically ill patient and family. Communicate and report pertinent observations and

inferences to appropriate personnel (i. e. instructor, team leader, etc.) promptly. Record

medications, treatments and subjective/objective observations properly in the patient's

record.

Assume responsibility for personal and professional growth in the medical-surgical

setting. Accept responsibility for his own actions/behaviors as a student member of the

health care team. Is prepared with pre-care level patient data prior to each clinical lab day.

Report promptly to clinical laboratory and pre/post conferences. Constructively use

instructor's feedback by initiating appropriate actions in subsequent written work or clinical

behavior. Identify specific experiences in clinical practice which are needed to accomplish

learning objectives. Appropriately seeks assistance where needed. Contribute to the growth

of self and classmates by sharing learning experiences on the clinical units during pre and

post conferences. Evaluate own clinical and academic performance based on these course

objectives

Utilize teaching-learning principles by implementing a standard teaching plan in a

structured setting. Identify the patient and family/significant others' responses to impact of

illness, hospitalization and treatments.