Medication Errors Course #109 2 contact hours Author: Monica Oram, RN, BSN This is NOT the Florida

Required course. (The Florida Required Course is #104, preventing medical errors) Upon completion of this course the reader will be able to achieve the following objectives: 1. Define what are medication errors 2. Recognize high alert medications 3. Understand importance of reporting errors 4. Factors that contribute to medication errors 5. Understand the five rights of medication administration What are medication errors? Medication errors are mistakes in the administration of drugs to patients. Medication errors can have serious results for our patients. Medication errors can cause pain and suffering, treatment delays, loss of income, and higher medical bills. Healthcare workers are also affected. It is an experience that can cause guilt, anxiety and self-doubt. Most medication errors can be easily avoided by double checking and being very careful as medications are administered. You can reduce medication errors by making certain: You can read the doctors orders You check the drug against the medication administration record Make certain you are giving it to the right patient Always question any dose that seems too high or too low. Your efforts will lead to greater patient satisfaction, and greater patient safety. You will experience greater job satisfaction by knowing you are practicing safely and efficiently.

Medication errors can occur: 1. When orders are not taken off properly, and carried out correctly. 2. Orders are incorrect. 3. Orders are not carried out at all. 4. Orders are unclear. Lets take a deeper looker.. When orders are not taken off properly, there can be many problems associated with medication errors. Many drugs look alike in name, or sound similar to others with a completely different purpose and effect. Errors can occur if a ward clerk takes off medication orders. Make certain that a nurse is double checking all orders against the physician orders to prevent a transcription error. If you are ever in doubt.check it out !!! Incorrect orders can include ordering the wrong drug, or the wrong dose. This can also be a particular problem if the person has a known allergy, and it is not noticed before the drug is ordered or given. When an order is not carried out, this is a medication error. Orders that fall through the cracks can be a serious problem to the patient in need of the medication. Unclear orders are a big problem that causes a lot of confusion. Confusion over what the order says often results in giving the wrong drug, or the wrong dose. All medication errors should be reported. All medication errors should be taken seriously! When orders are not carried out properly, this also creates a medication error, such as giving the right drug to the right patient, but giving it at the wrong time. Suggestions To Prevent Errors Beware of look alike and sound alike drugs- match the drugs indications with the patients diagnosis to prevent this common occurrence. One of the biggest liabilities and challenges for nurses is that we have a

license to protect. One of the big problems is that the physician orders the medication, the pharmacy fills the prescription, and the nurse administers the drug. Why is this a problem? This is a problem because there are several opportunities for an error to occur. The error can begin with the doctor prescribing the drug, or the pharmacy can make a mistake in filling the prescription. But it does not stop there.. The next liability falls on the nurse. Nurses have a lot of responsibility in ensuring that medications are given correctly. If a patient has a reaction, the nurse can be held liable because they are the one who gave the medication. Dont be mislead that all nurses are held liable for all errors. This is not really the case. Doctors can and do face liability as well when wrong medications are ordered. Pharmacies are also to blame at times for errors. The point is, that nurses must be mindful to what is being administered. Nurses should know to check out anything that does not seem right. Nurses should be aware of the complications associated with potential adverse reactions from drug interactions. So, if the doctor prescribed the drug correctly, and the pharmacy filled the prescription properly, and the nurse gives the medication which in turn causes harm to the patient, then the nurse can be held liable for this error. Nurses are most likely to be blamed for medication errors because they are involved at the administration level. Remember that medication errors are complex and are rarely ever the result of one persons actions. Statistical data suggests that when medication errors occur they can be broken down as follows: 35% of errors occur in the prescribing phase. 45% of errors occur in the nurse administration phase. 20% of errors occur in the pharmacy dispensing phase. Nurses today are faced with a tremendous amount of added responsibility, increased patient loads, and lack of sufficient staffing. With the increased workload and responsibilities, there are increased opportunity and chances for more medication errors to be made. Verbal orders a very high source of errors. When a nurse takes a verbal order, it is increasingly possible to interpret the wrong drug or dosage,

making the liability greater on the nurse who heard wrong or wrote it wrong as an order. Of the 45% of errors made by nurses, approximately 20% of these are due to verbal orders being taken incorrectly.

Suggestions To Help Avoid Errors Beware of look alike drugs and sound alike drugs Match the drugs indication with the patients diagnosis Maintain competency in drug delivery devices. No delivery device is safe unless the nurse can use it safely and properly. Use a system of double checks. Check concentration, flow rates, and drug to be given. Organize the workflow- working in a cluttered place, poor lighting, noise and interruptions make the preparation tasks more difficult and errorprone. (we all know that in the real world, these are a common occurrence and cannot be avoidable a lot of the time) Therefore, we have to know how to work in an environment that is conducive to providing safe patient care despite the environmental factors that are distracting) Educate the patients- encourage them to ask questions. Listen to your patient- sometimes they can be the last line of defense to avoid an error. Many are very aware of what medications they are receiving. Lets look a few examples: If a patient says something like, I have not taken a pill that looks like this before or I usually get only two pills in the morning (and you have more than two in the medication cup) DO NOT GIVE THEM THE MEDICATION until you go back and check it out. They may in fact be right, and avoid a potential error before it occurs. Healthcare professionals should remain educated and up to date on new medications. Invest in a good drug book and have it accessible on the job. Nurses are not doctors, and we are not pharmacists. We cant be a walking PDR, but we can be educated and knowledgeable to look up what we dont know. Promote error detection and correction to uncover a problem before it reaches the patient. Honest reporting of errors helps all health care professionals to devise changes in the system that are a potential problem.

Cause

COMMON CAUSES OF MEDICATION ERRORS Table Provided By Dana, 2001 and Fagan 2001 Description Example
The nurse has insufficient knowledge of the indications for use, available forms, correct dose, appropriate routes, adverse effects, toxicity, and compatibilities of the medication The nurse is unaware of a vital aspect of the patients condition Errors in which the nurse knew the rules and is not able to explain the error Errors in the ordering or verification process Problems communicating with others when transferring between services Errors in identifying the drug that results in patient getting the wrong medication Failure to ensure that the proper dose was given or dispensed Rapid infusion of vancomyacin causing a hypotensive episode

Lack of knowledge of the drug

Lack of information about the patient Forgetting and memory lapses

Administering insulin without knowing the patients blood sugar Missed doses of medication or duplicate doses of medications Writing 50 units of insulin vs. 5 units because the u looked like a zero Changes in Vancomyacin dose (related to peak and trough) not reported to a nurse Confusion with drugs that sound alike. Celebrex Vs. Celexa Hanging the same IV twice in a row, when two different IV medications were ordered alternately Infusion of TPN through a peripheral line instead of central line. Overdose of medication from pump not set correctly Physician not notified of critical lab values such as prothrombin time for a patient receiving coumadin Medications or IV meds not delivered in a timely manner Incorrectly prepared mixed insulin dose Heparin for IV flushes available in 1,000 units/ml and 10,000 units/ml

Transcription errors

Faulty interaction with other services Faulty drug identity

Faulty dose verification

Infusion pump and delivery system failures

Errors in setting up the infusion pump, confusion between central and peripheral lines, accidental tubing disconnections Failure to appropriately adjust the dose of medication because of necessary monitoring. ( lab values, vital signs) not done or ignored Late or missing deliveries of medication to the patient Errors in calculating and mixing drugs that result in incorrect dose Administration errors resulting from non-standard concentrations, dosing schedules, or infusion rates.

Inadequate monitoring

Drug stocking and delivery problems Preparation Error

Lack of standardization

Other Things To Consider

Abbreviations: When using abbreviations, stick to the standard abbreviations that all are familiar with. Illegible or confusing handwriting and communication failure often contribute to errors involving abbreviations. Examples of some problem abbreviations include: Handwriting a u for units. It can be mistaken for a zero.

Handwriting g instead of mcg. The can be mistaken for am M, and could be incorrectly interpreted at mg instead of mcg. Watch for leading decimals and trailing zeros. The use of trailing zeros such as 2.0 instead of 2, or the use of a leading decimal point, as in .2 instead of 0.2 are very dangerous practices. It is easy for a nurse to miss the decimal point and make an error that is TEN TIMES incorrect.

Remember that covering up an error is unacceptable. You put your patient, yourself , your license, and your organization on the line when reporting of errors are not done. Adverse event and error reporting is the professional and ethical responsibility of the nurse. Reporting near misses, even though no actual harm was done, is also very important to report. In the past, healthcare professionals have used the personal approach of: Aim, Blame, Shame, and Retrain That approach is not working. This is why the requirement of medical errors training has come about. We can learn from mistakes. A whole new approach is needed to not blame the individual making the error, but to look at systems that will improve and prevent the error from reoccurring. The Five Rights We all remember the five rights from nursing school. However, they are always worthwhile to review.

1. The right drug- read and reread the medication order and the drug label. When your facility changes drug vendors, take time to get familiar with the new labeling and markings. Be cautious of drugs that look alike and

2.

3.

4.

5.

sound alike. When taking verbal orders, ask the physician to spell out the name of the drug. Some manufacturers have even changed the names of drugs to prevent confusion. (Example: Losec to Prilosec, so as to not confuse it with Lasix) The right patient- Be careful of name alerts, or patients in the same room with same first name or similar last name. Place name alert stickers on charts and MARs as needed. Identify patient by name band if unfamiliar with the patient. Confused patients may answer to any name. Example: Do not ask a patient, Is your name ____? (a confused patient may say yes with no comprehension to who they are.) Pictures are helpful in LTC facilities. They need to be updated periodically though, because as they become sicker, gain weight or loose weight, the picture may no longer resemble the resident. These concepts are a particular concern if you work for a staffing agency, or if your facility utilizes agency nurses unfamiliar with the patients. The right dose- The use of decimals and trailing Zeros, (as discussed earlier.) Take into consideration weight and age when deciding if dose is appropriate and should be in question. If ever in doubt, call the doctor. Clarify any order that is unclear. If you have to make a drug calculation, ALWAYS have a second nurse double check your calculation. Get familiar with the normal doses of medications and invest in a good drug book. The right route- If the route is not specified, never assume it is oral.. It must be clarified. If a patients condition warrants a new route (ie: can no longer swallow pills, and requires liquid form) a new order must be written to reflect the change. If a liquid is used in place of oral, do not put in a syringe that could be mistaken for IV route. Spell out intravenous and international units so there is no confusion to IV&IU. Make sure all lines are labeled and dedicated for their purpose. The right time- Medications should be given on time. Medication should not be given any more than one hour before or one hour after the scheduled time. The right time should be scheduled around manufacturers recommendations of with food or on an empty stomach. If a medication cannot be given on time, document why.

In addition, the patient has the RIGHT TO BE EDUCATED and the RIGHT TO REFUSE. Right to be educated- Inform the patient what the medication is for and

potential side effects to be aware of that may need to be reported. Right to refuse- This is not a medication error, but does need to be documented as a refusal on the MAR. It should be documented in the medical record as well. Remember that if a patient refuses, it is not an error but if the nurse leaves it at the bedside, and the patient throws it away, then it is a medication error. MEDICATION CHECKLIST BEFORE Patients name band checked or patient identified before given? Medication checked against MAR before giving? Medication is right route? Drug/drug and drug/food allergies observed? Medication prepared immediately prior to administration? Pulse or blood pressure checked if indicated? Privacy respected (drapes with NGT, g-tube) Nurse aware of reason for med? DURING Medication correctly crushed or not crushed as directed, if needed? Calibrated measuring devices when needed? Liquids measured at eye level? Medication diluted if indicated? NGT or G-Tube flushed before and after administration? Liquids shaken? ( unless contraindicated) Oral inhaler used properly? Tablets or capsules not touched by hands while preparing? Medication given within one hour of scheduled time? Medication given with milk, water or antacid if indicated?

Practice the Three Time Check Read the label when you first get the medication

Read the label when preparing the medication Read the label just before giving the medication If you make a mistake ACCEPT RESPONSIBILITY Report any error to your supervisor. Take steps to correct the situation right away. HELP DETERMINE THE CAUSE This helps improve medication policies and procedures, and helps reduce future errors. FORGIVE YOURSELF No one is perfect. Most healthcare professionals have had at least one experience with a medication error. Help educate the larger medical community. There is an anonymous hotline, where errors can be reported to help health care professionals, drug manufacturers and others to learn from mistakes. You can report to the USP Medication Errors Reporting Program, operated in cooperation with ISMP ( Institute for Safe Medication Practices) Reports are made and retained in confidence, and used for statistical data and error research. www.ismp.org Summary Medication errors can be prevented if we take the added necessary steps to be more mindful of what we are doing. Those few extra minutes, that we dont have can save a patient a lot of grief and/or potential harm or even death. Remember, If in doubt, check it out. Practice safe, and practice Smart. The rewards will go along way in protecting your patients, and protecting your self from liability. Your efforts help ensure that patients get the medications they need--- safely! References: Mosby Drug Reference, 2003

Philadelphia, Pa. Springhouse Nursing Manual 2002, Springhouse, Pennsylvania Institute for Safe Medication Practices 1-800-23-ERROR www.imsp.org

Nurses' Six Rights for Safe Medication Administration

By Michelle Colleran Cook Below, is testimony provided by MNA Member Michelle Colleran Cook on behalf of the MNA Congress on Nursing Practice at a hearing before the Joint Committee on Health Care, which concerned the issue of prevention of medication errors in health care settings. My name is Michelle Colleran Cook. I am employed per diem in the Recovery Room of a Boston teaching hospital. I am also an instructor in a LPN School of Nursing and will graduate from Regis College with a Masters Degree in Nursing Administration in May 1999. Recently, there have been national and local incidences of nurse errors in medication administration that have resulted in negative patient outcomes. Nurses, because they administer the drugs directly to patients, are the last links in the safe medication administration chain. Complicating matters is the increased acuity of the patients they serve, and the decrease in the resources available to nurses to ensure safe practice. Because of the climate of health care today, nurses need to become cognizant of their practices vulnerability and vigilant about protecting their practice. All nurses have been taught the five rights of medication administration. They were drilled into our conscious in nursing school until they became part of our unconscious behavior as practicing nurses. The right patient, the right drug, the right dose, the right route and the right time form the foundation from which nurses practice safely when administrating medications to our patients in all health care settings. Just as nurses know the five rights of medication administration, they should also know what rights they have when administering medications. These "Six Rights for Nurses Administering Medications" will hopefully guide nurses as they continue to care for patients despite these turbulent times.

1.

THE RIGHT TO A COMPLETE AND CLEARLY WRITTEN ORDER You, as the nurse, have the right to demand that an order be complete and clearly written. You have the right to require that the drug, dose, route and frequency be written by the physician. All of these components must be present for a physician order to be considered complete. It is no longer good practice to accept orders when the dosage is written as "1 tablet." A complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be specific and the dose explicit.

Verbal orders should never be taken and telephone orders should only be taken if the physician is not physically present. Nurses cognitively know this but often in the interest of saving time may be tempted not to practice it. Nurses who write orders for physicians are placing their license and their patients at risk. Orders should be legibly written. The Massachusetts Hospital Coalition recommends physicians use computers to directly order medications. However, such costly systems may take years to implement. Until that occurs, nurses need to remember that it is their duty and right to question physician orders that are illegible. Cefoxitan and Cefotetan may look alike when hand written but confusing one drug for the other results in the patient receiving the wrong medication.

2.

THE RIGHT TO HAVE THE CORRECT DRUG ROUTE AND DOSE DISPENSED Nurses administer medications but it is the pharmacys duty to dispense medications correctly. Pharmacies process and distribute an incredible volume of medications daily. Pharmacists, like nurses, are susceptible to the pressures of time and patient needs and can dispense the incorrect drug or dose. The nurse who discovers the error then notifies the pharmacy of this oversight. If all goes well, pharmacy will deliver the medication promptly to the nursing unit. In this case the system works well. Sometimes, the nurse is told there is no one from pharmacy available to deliver the medication. The nurse is given the option of either waiting for her patients medication, coming to the pharmacy herself to get the medication, or finding someone else to do so. Such errors of dispensing eat away at nursing time and energy. They pull nurses away from caring for their patients. They place patients in jeopardy of not receiving the drug on time. Additionally, unnecessary stress is placed on the nurse who is struggling just trying to gather the drugs necessary to care for her patient. This hurried atmosphere places the nurse in a position that she may make a medication error in her haste. Another recommendation from the Massachusetts Hospital Coalition states that a unit dose system of medication can decrease the number of medication errors. Many hospitals have adopted this system of medication administration. However, scenarios such as the one above coupled with the available technology of automated medication administration systems such as the Pixis has placed nurses in a potentially unsafe situation. First developed to dispense narcotics, these automated systems can be programmed to allow nurses access to many other types of medications. Now, in an attempt to address missing or incorrectly dispensed medications, and decrease the turnaround time of getting the correct drug to the patient, they are being used widely in acute care hospitals as quasi satellite pharmacies. At first, they may be seen by the nurse as a welcome relief from the frustration of not having medications readily available to administer. But they must be used with caution. The nurse enters patient data into the automated medication dispenser; the machine opens the

correct drawer and directs the nurse to the correct drug compartment where the medication can be found. But in some systems, when the Pixis drawer opens, the nurse has access to many drugs. In this situation, the unit dose safeguard is eliminated and therefore increases the chances of the nurse selecting the incorrect drug or dose and administering it to their patient.

3.

THE RIGHT TO HAVE ACCESS TO INFORMATION Nurses have the right to expect updated and easily accessible drug information. This means that the hospital formulary, a Physicians Desk Reference and a current nursing drug reference book need to be available to nurses who administer medications. Nurses have the right to ask questions about the drugs that they are to administer to their patients. Pharmacists are the drug experts and nurses should have access to a pharmacist no matter what time of day. Hospitals need to have a pharmacist available on a 24-hour basis. More dialogue between nurses and pharmacists can only improves patient outcomes and decreases the chances of medication errors occurring. As pharmacology and technology advances, patients should be able to expect a nurse who is continually updated on new medications and the ways they are delivered. Good nursing practice dictates that nurses are never to administer a drug they are unfamiliar with. If a patient is to receive a drug that is too new to be in the usual reference books, nurses should insist that information be provided to them. And they should not administer that drug until they have enough information to be comfortable doing so.

4.

THE RIGHT TO HAVE POLICIES ON MEDICATION ADMINISTRATION It is the responsibility of health care administration to provide the structure necessary for nurses to administer medications safely. Nursing practice is governed by the Board of Regulation in Nursing but nursing policies are what guide nursing practice at that health care entity. Policies often protect the nurse from litigation should an error occur. Conversely, not following policy or administrating medication without a policy will put the nurse at risk not only for litigation but can result in license suspension or forfeit. New medications enter the market daily. Research discovers new uses and ways to administer old medications. Administrators are not practitioners; they need to be updated by staff on new trends in medication administration. Subsequently, nursing administrators need to initiate and develop systems that promote safe medication administration. Nursing administrators have to insist that nurses of their organization be allowed to deliver patient care in the safest environment possible.

5.

THE RIGHT TO ADMINSTER MEDICATIONS SAFELY AND TO IDENTIFY PROBLEMS IN THE SYSTEM Nurses are the experts on what impacts safe medication administration. Shaping systems and creating solution for safe medication administration should include those who actually

do the work of administering medications. Nurses have the right to speak up when they see situations that can potentially result in medication errors. System glitches that place the patient at risk need to be addressed and corrected. Repeated breaks in the system can only be fixed if at first it is identified. Just as you would advocate for a patient, you should advocate for your ability to practice in a safe setting. Your input is of tremendous value to all.

6.

THE RIGHT TO STOP, THINK, AND BE VIGILANT WHEN ADMINISTERING MEDICATIONS Nurses know medication administration is serious business. Often nurses are caught up in the hustle and hassle of a busy work place. With decreases in licensed staff and organizational support and increasing patient acuity, nurses still manage to do it all. But we are human, we are all fallible. There is only so much sensory input a person can handle, only so many questions one can process at a time. When we find our minds so overloaded we are unable to think. We have the right to stop and do so. When we see orders that somehow do not make sense even if we can not identify why this order seems odd, we have the right to stop and find out why. When we are about to administer a drug we are unfamiliar with, we have the right to stop and find out about this new drug. If we need to ask other nurses or professionals about this drug or check the policy for giving this drug, we need to stop and do so. Will this take additional time? Yes. Will others think we are stupid? Maybe. Will some people become irritated with us? Probably. But, if stopping to think before administering medications to your patient seems like an inconvenience, ask yourself this question: Would I rather be known as the nurse who is slow giving her meds, or the nurse who did her patient harm? Unsafe medication administration situations will be lessened as long as nurses continue to recognize problems and steadfastly protect their patients and their practice. Nurses need to take the time to identify and address sloppiness in their work place and in other professionals. Confrontation is not easy for nurses. Nurses would rather fix it themselves. This system only perpetuates others poor practice and allows the nurse to assume responsibility for all. This is not our job. Our allegiance is to our patients.

Course Description
Practical application of knowledge and skills required for nursing care of adult patients with commonly occurring acute/critical medical-surgical problems is demonstrated in both Lab and clinical settings. Concurrent enrollment in NSG 320 is required unless approved by the Department Chair. Clinical Lab is graded on a Satisfactory/Unsatisfactory basis based on successful completion of the course requirements.

Learning Outcomes
Provide standardized nursing care to a group of adult, acutely/critically ill patients in a structured setting. Perform nursing skills safely and effectively. Administer nursing care based on the patient's present bio-psycho-social-cultural-spiritual situation. Determine the patient's priority of needs and plan care accordingly. Complete nursing care for at least three adult patients on time using an organized and efficient approach. Utilize the nursing process to administer care to the adult patient with commonly occurring health care needs and problems. Collect data on the patient's health status in a systematic and objective manner using the system's review. Assess the data considering the normal physiologic and psychologic parameters of the adult, acutely/critically ill patient's experience and identify the assets and deficits of that experience. Formulate a nursing diagnosis for each actual or potential problem which has been identified from the patient's health assessment. Devise a nursing care plan which provides nursing interventions to the patient as needed and reflects awareness of the priority problems in the care of the patient. Implement the plan of care and state the rationale for the nursing interventions. Evaluate the effectiveness of the care based on the stated expected outcomes or goals of care. Provide appropriate health information to the patient and family using standardized teaching plans. Assess the patient as to their learning needs and knowledge deficits. Implement a standard teaching plan to meet the patient's learning needs. Evaluate the effectiveness of that experience. Identify hospital as well as community resources available to patients and make referrals following consultation with team leader or instructor. Utilize therapeutic communication skills, guidance and support in interacting with the adult patient and family and record observations in proper sequence and format. Recognize own values and behavioral responses which may be conditioned by own culture and experiential background. Provide therapeutic and supportive communication to the adult, acutely/critically ill patient and family. Communicate and report pertinent observations and inferences to appropriate personnel (i. e. instructor, team leader, etc.) promptly. Record medications, treatments and subjective/objective observations properly in the patient's record. Assume responsibility for personal and professional growth in the medical-surgical setting. Accept responsibility for his own actions/behaviors as a student member of the health care team. Is prepared with pre-care level patient data prior to each clinical lab day. Report promptly to clinical laboratory and pre/post conferences. Constructively use instructor's feedback by initiating appropriate actions in subsequent written work or clinical behavior. Identify specific experiences in clinical practice which are needed to accomplish learning objectives. Appropriately seeks assistance where needed. Contribute to the growth of self and classmates by sharing learning experiences on the clinical units during pre and post conferences. Evaluate own clinical and academic performance based on these course objectives

 Utilize teaching-learning principles by implementing a standard teaching plan in a structured setting. Identify the patient and family/significant others' responses to impact of illness, hospitalization and treatments.