Unit 13 Ch 10: Med Incidents + Risk Reduction

Medication incident

include medication errors and adverse drug reactions; impede pharmacotherapeutic outcomes, increase hospitalization costs, and can result in serious injury or death

Adverse drug reaction

undesired and unexpected client response to an administered medication

Medication errors

situations where the wrong drug/med is prescribed or given, the med is improperly administered, or an incorrect dosage or protocol is used

- most common single preventable cause of client injury

Canadian Medication Incident Reporting and Prevention System (CMIRPS)

national medication incident reporting and prevention system; categorizes errors with an algorithm

Category A

circumstances or events that have the capacity to cause error;

Category B

an error occurred but the error did not reach the client (an "error of omission" does reach the client);

Category C

an error occurred that reached the client but did not cause client harm

Category D

an error occurred that reached the client and required monitoring to confirm that it resulted in no harm to the client and/or required intervention to preclude harm

Category E

an error occurred that may have contributed to or resulted in temporary harm to the client and required intervention

Category F

an error occurred that may have contributed to or resulted in temporary harm to the client and required initial or prolonged hospitalization

Category G

an error occurred that may have contributed to or resulted in permanent client harm

Category H

an error occurred that required intervention necessary to sustain life

Category I

an error that may have contributed to or resulted in the client's death

Factors contributing to med incidents

- failing to adhere to the 10 rights

- failing to follow agency procedures or consider client variables

- giving meds based on verbal orders

- not confirming illegible or incomplete orders

- working under stressful conditions

Most frequent categories of errors

- errors in client assessment

- inaccurate prescribing

- errors in admin

High-alert meds

drugs that bear a heightened risk of causing significant client harm when used in error

Documenting and reporting med incidents

- document in client's medical record with interventions that were implemented following the incident

- written incident report

- reporting at national level

Medication reconciliation

- a review of all the meds a client is/should be taking to compare with newly ordered meds

- should occur anytime there is a change in the site of the client's care

Polypharmacy

use of multiple medications; may have conflicting pharmacological actions

Strategies for preventing med incidents

- adhering to ADPIE

- med checks

- correct procedures + aseptic techniques; sterility

- calculate carefully

- always confirm pt has swallowed

- keep up to date on pharmacotherapeutics

- know common types of med errors

Client med education strategies

- provide med handouts

- encourage them to keep a list of everything they are taking + to report them to HCPs

- educate them on the meds

Factors of nonadherence

- forgetting doses

- expensive

- annoying adverse effects

Healthcare agency risk management implementations

- e-prescribing

- barcode-assisted med admin (BCMA)

- automated, computerized, locked med cabinets

- risk management departments

- root-cause analysis (RCA)

E-prescribing

electronic transmission of prescription-related info to a pharmacy or HCP

- reduces the risk of med errors

Barcode-assisted medication administration (BCMA)

technology used to verify and document medication administration at the point of care, usually the patient's bedside, by scanning a barcode on the patient's wristband

Root-cause analysis

analyzes data post-occurrence and asks

- what happened?

- why did it happen?

- what can be done to prevent it from happening again?

- has the risk of recurrence actually been reduced?

Other institutional polices + procedures

- store meds under proper conditions

- read drug label to avoid administering time-expired meds

- avoid transfer of doses from one container to another

- avoid overstocking

- monitor adherence to avoiding use of prohibited abbreviations

- remove outdated reference books