unit 2

what is a medication error?

any preventable event that can lead to inappropriate medication use or patient harm while the medication is under control of the health care professional, patient, or consumer

what factors contribute to medication errors?

• failure to follow 3 checks and 5 rights

• failure to assess patient (age, body size, labs, kidney/liver impairment)

• incomplete/unclear med orders (illegible, verbal orders)

• system/work issues (stress, acutely ill patients » sudden onset, high severity, short duration)

• patient/caregiver may also contribute

  • not telling providers about all medications from multiple prescribers

  • using multiple pharmacies

  • not filling or refilling prescriptions

  • not following directions (wrong dose, time, or schedule)

  • taking leftover from previous illness or someone else’s medications

what systems are used to report medication errors?

• FDA Safety Information and Adverse Event Reporting

  • voluntary + mandatory reporting of medication errors and adverse events

• NCC MERP

  • promotes medication safety and reporting to prevent errors

• FDA’s Division of Medication Error Prevention and Analysis

  • reviews reports and recommends safety changes (labels, names, packaging)

what should you include when documenting a medication error?

• more than simply recording that med error occurred

• specific nursing interventions

• all individuals who were notified of the error

• MAR should contain information about what medication was given or omitted
  

how do you report medication errors?

• complete written report (ex: incidence reports, occurrence reports)

• include specific, factual, and objective details

• identify factors that contributed to med error

• used for quality improvement

what can the nurse implement to reduce medication errors?

• assess

  • allergies, use of other meds, body system functions

• plan

  • question unclear orders, avoid abbreviations that can be misunderstood, follow facility policy, ask patient to demonstrate understanding

• implement

  • eliminate distractions, two identifiers, correct procedures/techniques, med dosage calculations, record/document, confirm patient has swallowed medication before walking away, never leave meds at bedside, be alert for look alike/sound alike and do not crush list

• evaluation

  • asses for expected outcomes, determine if adverse effects occurred

• never administer med without being familiar with its uses and side effects

what is the To Err is Human report?

• brought attention to medical errors

• set forth national agenda with federal/state/local implications on how to reduce med errors and improve safety

• “good people working in bad systems”

what is the Joint Commission Accreditation?

• focus on patient safety and quality of care

• institutions desiring JCAHO accreditation must adhere and demonstrate compliance to the standards it puts forth, including med management and safety measures

• National Patient Safety Goals

what is the nurse’s role and responsibility regarding safe drug administration?

• have strong grasp of pharmacology content

• following nursing process with med admin

• practice principles of safety at all times to avoid errors and harm

• provide pt teaching about meds to allow pts to safely gain autonomy and control over their conditions

• follow the CA RN State Practice Act in accordance with the RN Scope of Practice

what are the rights of medication administration?

• right client

  • use 2 identifiers

• right medication

  • check generic name, expiration date, allergies

• right time

  • meds have a specific window during which they should be given to maintain a therapeutic dose » otherwise, under-dose or near miss drug error

• right dosage

  • some meds require 2 nurses to check dosage

• right route/site

  • onset of action is highly dependent on route

• right documentation

what is medication reconciliation?

• process of tracking meds as pt proceeds from one HCP to another

• lists all meds pt is taking to reduce duplications, omissions, dosing errors, or drug interactions

what is polypharmacy?

taking more than 5 meds

what are special safety guardrails?

• high risk meds

• black box warnings

• look-alike/sound-alike