Term
| Define a medication error! |
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Definition
Any error that occurs in medication administration process, whether or not it harms the patient.
May be applied to:
Misinterpretation
Miscalculation
Misunderstanding of verbal order |
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Term
| What are some contributing factors that lead to medication errors? |
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Definition
BY HC provider-Omitting one of the rights of drug administration
Failing to perform an agency system
check
Failing to take into account for patient variables (age, body size, and renal or hepatic function)
Giving medications based on verbal orders or phone orders
Giving medication based on an incomplete or illegible order
Practicing under stressful working conditions |
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Term
| Medication errors that involve the patient? |
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Definition
Taking drugs prescribed by several practitioners
Getting prescriptions filled at more than one pharmacy
Not filling prescriptions
Taking medication incorrectly
Taking meds from a prior illness
Taking med prescribed for something else |
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Term
| Who is the second viction of medication errors? |
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Definition
Person responsible for error feeling shame, and doubt
May have anxiety, sleeplessness
Depression or Suicide |
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Term
| How do you report and document medication errors? |
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Definition
Document in a factual manner
Include specific interventions that were implemented following error in order to protect the patient
Document all individuals involved
MAR as a source of detail of what was given or omitted |
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Term
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Definition
Is not part of the patients medical record
Used by agency risk management for quality improvement
Reduction of medication errors can be created from written data
Root cause analysis (RCA) seeks to prevent another occurrence by asking what happened and why, and what can be done to prevent it. |
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Term
| What is a sentinel event? |
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Definition
Unexpected occurrences involving death
or serious physical or psychological injury or risk
Always investigated
Interventions taken to ensure there is no repeat |
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Term
| What shuld nurses know and do regarding medications? |
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Definition
Nurses should know the most frequent types of drug errors and severities of reaction
Nurses should not administer medications unless familiar with uses and side effects |
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Term
| What are the most frequent types of medication errors? |
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Definition
Administer improper dose
Giving wrong drug
Using wrong route of administration
One half of fatal medication errors occurred in clients older than 60 years of age
Children are also vulnerable population due to smaller dosages |
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Term
| What is medication reconcilliation? |
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Definition
JC requirement
Process of ‘keeping track’ of a patients medications as they proceed from one health care provider to another
Polypharmacy – patients having multiple prescriptions that may have conflicting pharmacologic actions
Med errors tracked to poor med reconciliation
Reconciliation lists all medications a patient is taking to reduce errors
Hospitals are encouraged to document a complete list when patient is admitted |
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Term
| What can we do to reduce med errors? |
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Definition
Be aware of potential distractions during medication administration
Remove distractions if possible
Focus on task of administering medications
Practice the rights of medication administrations
Use electronic forms of drug administration when available (Essentris or Pyxis, EPIC/MAR |
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Term
| What other things can you do to help reduce medication errors? |
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Definition
Keep in mind:
Positively verify patient using the name and BD
Use correct procedures for all routes of admin.
Calculate medication doses correctly
Open medications prior to administering
Label meds not in original containers
Record on MAR immediately after administering |
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Term
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Definition
Written, age appropriate handouts
Audiovisual teaching aids
Contact information
Names of meds
Side effects of med
Use appropriate administration devices
Real label prior to each administration
Carry list of all medications, including OTC and herbals
Ask questions! |
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Term
| Examples of beneficial policies and procedures |
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Definition
Correct storage of medications
Reading drug label
Avoid drug transfer between containers
Avoid overstocking to prevent expiration, Monitor compliance with current med abbreviations, Removing outdated reference books |
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Term
| What are way the goverment track med errors? |
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Definition
FDA’s MedWatch
HC providers encouraged to report errors
Errors may be reported anonymously
ISMP – Institute for Safe Medication Practices
MEDMARX- US Pharmacopeia’s anonymous medication error reporting program |
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