Medication error

1. MEDICATION
ERROR

2. INTRODUCTION
A medication error is a failure in the treatment process that leads to, or has
the potential to leadto, harm to the patient. Medication errors can occur in
deciding which medicine anddosage regimen to use (prescribing faults—
irrational, inappropriate, andineffective prescribing, under prescribing,
overprescribing); writing the prescription (prescription errors);
manufacturing the formulation (wrong strength, contaminants or
adulterants, wrong or misleading packaging); dispensing the formulation
(wrong drug, wrong formulation, wrong label); administering or taking the
medicine (wrong dose, wrong route, wrong frequency, wrong duration);
monitoring therapy (failing to alter therapy when required, erroneous
alteration).

3. MEDICATION ???

4. DEFINITION OF MEDICATION ERROR
•“Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in control of the health care professional,
patient, or consumer”.
•A medication error can be defined as “a failure in the
treatment process that leads to, or has the potential to lead
to, harm to the patient.”

5. PURPOSE OF MEDICATION
• It is usedfor diagnosis.
• It treats the disease condition.
• To treat health alterations.
• To promote health conditions .
• To treat infections allergies andinflammation.
• To relieve pain.
• To restore bodily functions.

6. Inaccurate recording and transcribing orders.
Unclear or erroneous labeling of drugs.
Misidentification of client.
Incomplete delivery of drugs.
Verification errors.
Use of inadequate knowledge or inaccurate knowledge base.
Time and performance pressure.

7. CAUSES
Distraction :
• A nurse who is distractedmayread "diazepam" as "diltiazem." The outcome is not
insignificant-if diazepamis accidentally administered, it couldsedate the patient, or worse
(e.g., if the patient has an allergy to the drug).
Environment :
• A nurse who is chronically overworked can make medication errors out of exhaustion.
Additionally, lack of proper lighting, heat/cold, and other environmental factors can cause
distractions that lead to errors.
Lack of knowledge/understanding :
• Nurses who lack complete knowledge about how a drug works, its various names (generic
and brand), its side effects, its contraindications, etc. can make errors.

8. CAUSES
Incomplete patient information :
• Lacking informationabout whichmedications a patient is allergic to, other medications the patient is
taking, previous diagnoses, or currentlab resultscan all leadto errors. Nurses who aren't sure should
alwaysask the physician or cross-checkwithanother nurse.
Memory lapses :
• A nursemay knowthat a patient is allergic, but forget. This is oftencaused by distractions. Forgetting
to specify a maximumdaily dose for an "as required" drug is another example of a memory-based
error.
Systemic problems :
• Medications that aren't properlylabeled, medications with similar names placedin close proximityto
one another, lack of bar codescanning system, and other issues can lead to medical errors.

9. TYPES

10. TYPES DESCRIPTION
1. Prescribing errors , wherein the selection of a drug is incorrect based on the patient's
allergies or other indications. Additionally, the wrong dose, form,
quantity, route (oral vs intravenous), concentration, or rate of admission
could be used.
2. Omission errors in which there is a failure to give a medication dose before the next one is
scheduled.
3. Wrong time errors wherein a medication is given outside the predetermined interval from
its scheduled time.
4. Improper dosing errors wherein a greater or lesser amount of a medication is delivered than is
required to manage the patient's condition.
5. Wrong dose errors wherein the correct dosage was prescribed, but the wrong dose was
administered.
6. Improper administration technique errors such as administering a medication intravenously instead of orally.
7. Wrong drug preparation errors wherein a medication is incorrectly formulated (i.e., too much or too little
diluting solution added when a medication is reconstituted).
8. Fragmented care errors wherein a lack of communication exists between the prescribing
physician and other healthcare professionals

11. ACTION TAKEN WHEN ERROR OCCURS
 The client safety becomes the top priority.
 The nurse assesses andexamines the client’s condition and notifies the
physician of the incident as soon as possible.
 Once the client is stable the nurse reports the incident to the
appropriate person in the institution like nursing supervisor or nursing
manager.
The nurse is also responsible for reporting the incident. An incident
report usually must be filedwithin 24hours of an incident.

12. Continued..
 The report includes client identifying information, the location and time of the
incident, an accurate factual description of what occurredand what was done,
the signature of the nurse involved. The incident report is not a permanent part
of the medical record and shouldnot be referred to in the record. This is to
legally protect the health care professional and institution.
 The institution use incident report to track incident patternand to initiate
quality, improvement programs as needed.
 It is good risk management to report all medication error including mistakes
that do not cause obvious or immediate harmor near misses.

13. Safety measures
PREVENTINGMEDICATIONERRORS
• Nurses may not havethe authorityto make infrastructural changes, but they do havethe
power to suggest neededchanges and take precautions to prevent medication errors, including
the following:
 KNOW THE PATIENT:
• This includes the patient's name, age, date of birth, weight, vital signs, allergies, diagnosis, and
current lab results. Don't make this potentiallydangerous mistake-use all of the information
at your disposal to ensure patient safety, and avoid shortcuts.
 KNOW THE DRUG:
• Nurses needaccessto accurate, current, readily available drug information, whether the
informationcomes fromcomputerized drug information systems, order sets, text references,
or patient profiles. If you have any questions or concerns about a drug, don't ignore your
instincts-ask. Remember that you are still culpable, even if the physician prescribedthe wrong
medication, the wrong dose, the wrong frequency, etc.

14.  KEEP LINES OF COMMUNICATION OPEN:
• Breakdowns in communicationamong physicians, nurses, pharmacists, and others in the healthcare
systemcan lead to medicationerrors. The "SBAR" methodcan help alleviate miscommunications. SBAR
(Situation, Background, Assessment, Recommendation) works likethis:
 Situation : "The situationis that Mr. Smithis complaining of chest pain."
 Background : "He had hip surgeryyesterday. About two hours ago he begancomplaining of chest
discomfort. His pulse is 115, and he is short of breathand agitated."
 Assessment : "My assessment is that Mr. Smithmay be having a cardiac event."
 Recommendation : "My recommendation is that you see himimmediately, and that we start
himon O2 and administer an analgesicimmediately. Do youagree?"
• Communicationis vitally important, as it is the root cause of manysentinel events, according to the Joint
Commission.

15.  DOUBLE CHECK HIGH ALERT MEDICINES:
• High-alert medicines such as heparin canhave devastating consequences if not administeredproperly.
A tragic case involving the death of three infant patients after receiving massive heparinoverdoses
happened as a result of misleading packaging. Since this incident, the drug manufacturer now uses larger
fontsizes, tear-off cautionary labels, and different colors to distinguish drug doses.6 Medications often
lookalike and soundalike-this can be a source of errors. Double check high alertmedications with
another nurse to prevent accidental overdoses and other medicationerrors.
 DOCUMENT EACH DRUG ADMINISTERED:
• Accurate documentationis essential and shouldinclude accurate recording of the drug information, the
name of the drug, the dose, route, time, patientresponse, and any refusal of the drug by the patient.
 TAKE AN ACTIVE ROLE IN CORRECTING ISSUES YOU IDENTIFY:
• If yousee that look-alikeor sound-alike medications are storednext to eachother, ask your supervisor to correct
the problem, emphasizingthe increasedrisk of medication errors. Request that medications be reconciled(i.e.,
that the names, dosages, and administration routes of all medications are comparedto identifyconflicts). Request
that a bar coding system be implemented that allows for the verification of the six medication rights (right
individual, right medication, right dose, right time, right route, right documentation).

16.  INFORM THE PATIENT OF THE DRUGS THEY ARE RECEIVING:
• Makesure your patients knowthe names of the medications they are taking, what theylook like,
what they are for, how to take themor how theywill be administered, the dosage, and the potential
side effects and interactions.
 ASK FOR CONTINUING EDUCATION:
• Ask for mandatory training sessions about medications that are introduced to your facility. Training
should include medication-related policies, procedures, and protocols. Updates likethese, along with
comprehensivenurse CE programs that include healthcare videos, empower nurses and can help
prevent medicationerrors.
• Nurseeducators and continuing education providers should include all of theseprevention tips, and
more, in nurseeducation programs to help nurses avoidmedicationerrors that could have
detrimental or evendeadly consequences for patients, and significantconsequences for nurses,
including disciplinaryaction, job dismissal, criminal charges, and mental anguish.

17. STAGE SAFETY STRATEGY
Prescribing  Avoid unnecessary medications by adhering to conservative prescribing principles.
 Computerized provider order entry, especially when paired with clinical decision support system.
 Medication reconciliation at times of transitions in care.
Transcribing  Computerized provider order entry to eliminate handwriting errors.
Dispensing  Clinical pharmacists to oversee medication dispensing process.
 Use of "tall man" lettering and other strategies to minimize confusion between look-alike, sound
alike medications.
Administration  Adherence to the "Five Rights" of medication safety (administering the Right Medication, in the
Right Dose, at the Right Time, by the Right Route, to the Right Patient).
 Barcode medication administration to ensure medications are given to the correct patient.
 Minimize interruptions to allow nurses to administer medications safely
 Smart infusion pumps for intravenous infusions.
 Patient education and revised medication labels to improve patient comprehension of
administration instructions.

18. SIX STEP APPROACH BY WHO FOR
GOOD PRESCRIBING
 Evaluate & clearly define patient’s problem.
 Specify therapeuticobjectives.
 Select appropriate drug therapy: P-drug & STEPS approach (Safety,
Tolerability, Effectiveness, Price, Simplicity).
 Initiate therapy with appropriatedetails.
 Give information, instructions & warnings.
 Evaluate therapy regularly (e.g. Monitor treatment results).

19. ROLE OF NURSE
 Education & proper training important in reducing
medication related errors .
Most errors do not reachpatient because of barrier role
played by a nurse.
 Independent calculations of paediatric doses by more
thanone person .
 Should be aware of correct storage requirements for
drugs.
 Development of standardized dose & rate charts for
products such as vasoactive drugs 44.

20. A final word on medication errors:
"Don't ask, don't tell" is never a smart policy when it comes to
medications and your health. Don't hesitate to ask questions or to
tell your health care providers if anything seems amiss.
Remember, you're the final line of defense against medication
errors.
If despite your efforts you have problems with a medication, talk
with your doctor or pharmacist about whether to report it to Med
Watch — the Food and Drug Administration safety and adverse
event reporting program. Reporting to Med Watch is easy,
confidential and secure — and it can help save others from being
harmed by medication errors.