Daviss Drug

Guide for Nurses, 12th Edition

Medication Errors
Improving Practices and Patient Safety

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Causes 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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Medication 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 Daviss Drug Guide for Nurses for a list of high alert drugs

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Selected Elements of the Medication Use 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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 factor of 10

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 Daviss Drug Guide for Nurses for a table of error-prone abbreviations and safer alternatives

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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!

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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!

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Labeling 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 Daviss Drug Guide for Nurses for a list of drugs requiring Tall Man lettering

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Dose Miscalculations

Major cause of medication errors Can be a mathematical error or a failure to consider patients age; renal or hepatic function; or other modifying factor Includes miscalculation of dosage or rate of administration and misprogramming of infusion pumps

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Incorrect Drug Administration

Dont forget the 5 Rights

Right drug

Right patient
Right dose Right route Right time

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Human and Environmental Factors That Influence Errors

Distractions Poor staffing Culture of perfection Questioning physicians is tacitly discouraged

Punitive response to error (shame and blame)

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Prevention 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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

Prevention Strategies for Nurses (Contd)

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 Daviss Drug Guide or a pharmacist

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 the nurse's/clerk's transcription against the original order; make sure stray marks or initials do not obscure the original order

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 independently check original order, dosage calculations, and infusion pump settings for high alert medications

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 Nurses for more information about patient education

Copyright 2011 F.A. Davis Company

Daviss Drug

Guide for Nurses, 12th Edition

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 online
https://www.accessdata.fda.gov/scripts/medwatch/

Or by phone: 1-800-FDA-1088

Copyright 2011 F.A. Davis Company