MEDICATION ERRORS

Medication Errors

  • Definition: Clinical issues resulting from medication use, including medication errors and adverse drug reactions (ADRs).

Types of Medication Errors

  • Near Miss: Did not reach the patient, no harm.

  • No Harm Event: Reaches patient, no harm.

  • Medication Error: Causes harm.

  • Critical Incident: Results in serious harm.

Statistics and Impact

  • Landmark IOM study (1999): 44,000-98,000 deaths/year in the US due to medication errors.

  • 1.5 million patients harmed annually; 117,000 hospitalizations at a cost of $4 billion.

  • Canadian studies indicate 9,000-24,000 deaths/year due to adverse events.

Medication Safety Organizations

  • CMIRPS

  • ISMP Canada

  • CPSI

  • Health Canada

  • CIHI

Just Culture

  • Error reporting should focus on systems rather than punitive measures.

  • Accountability and remediation are needed in workplace culture and reporting structures.

Most Common Causes of Medication Errors

  • CNS drugs, anticoagulants, chemotherapeutic drugs.

High-Alert Medications

  • Look-alike, sound-alike drugs (SALAD and LASA).

Medication Administration Rights

  1. Right medication

  2. Right dose

  3. Right patient (2 identifiers)

  4. Right route

  5. Right time

  6. Right reason

  7. Right documentation

  8. Right education

  9. Right to refuse

  10. Right evaluation

Considerations for Older Adults

  • Increased risks due to polypharmacy and physiological changes.

  • Require smaller doses; may need special aids for medication management.

Mitigating Risk as a Nurse

  • Double-check calculations; report ADRs immediately.

  • Never administer medications prepared by others, clarify unclear orders.

  • Use leading zeros for doses and avoid trailing zeros.

  • Keep updated on current practices and conduct medication reconciliation.

Responding to Medication Errors

  • Follow facility policy, document facts without judgment, notify appropriate personnel, monitor ongoing patient status.

Pediatric Medication Errors

  • Most common cause of harm in pediatric patients; higher risk of death.

  • Dosing errors are more frequent; follow the Ten Rights of medication administration actively.

Medication Reconciliation

  • Compare pre-admission medications with those provided during care to prevent interactions and errors.

  • Conduct reconciliation at admission, status changes, transfers, and discharge.