Transcript Medication errors

MINIMISING MEDICATION
ERRORS
Medication Errors
Aims.
– To discuss the number and types of medication
errors and the ways in which they may be
minimised
– To demonstrate how analysis of reported
incidents can identify systems errors.
– To raise awareness of reporting ‘near misses’
Medication Errors
Objectives.
To increase understanding of the
– Systems errors which lead to medication
errors.
– Potential risks associated with the
administration of medications
– Basis for reviewing the drug administration
process.
– Trust policy on drug administration.
Percentage of nurses time spent on medication
related activities by grade
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F
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Percentage of nurses time spent on medication
activities
prep
check
admin
chart
NMC RULES
The NMC expects any nurse to
administer medications in a technically
safe manner and to make a clinical and
professional contribution to the
process.
Principles of safe care drug administration
7 R’s
 Right Drug
 Right Patient
 Right Time
 Right Route
 Right Date
 Right Prescription
 Right Dose
So you think you are a safe drug
giver?
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1. How often are you asked to check another persons
drugs at the same time you are dispensing
medication? (Sometimes: 2)(Never: 0)
2. How often do you try to do two things at once, i.e.
answer the telephone and check drugs?
(Sometimes: 2) (Never: 0)
3. If you are preparing a familiar drug how often do
you guess at the dose if you could not read the
doctors handwriting? (Sometimes: 2) (Never: 0)
4. How often do you ‘cut corners’ in implementing the
drug administration policy? (Sometimes: 1) (Never: 0)
5. Have you ever made a drug error? (Y: 2) (N: 0)
So you think you are a safe drug
giver?
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6. How often have you given a drug to an in-patient
who was not wearing a name band?
(Sometimes: 1) (Never: 0)
7. How often do you administer drugs that have not
been prepared and checked by you?
(Sometimes: 1) (Never: 0)
8. How often do you take verbal messages?
(Sometimes: 2) (Never: 0)
10. Are drugs stored within locked cabinets and
cupboards? (Y: 0) (N: 1)
So you think you are a safe drug
giver?
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11. How often are drugs left out unattended?
(Sometimes: 2) (Never: 0)
12. Is there efficient ordering and stock management
which keeps stocks well in date etc? (Y: 0) (N: 2)
13.Do you feel able to question ALL staff including
senior nurses/ medical staff? (Y: 0) (N: 2)
14. Is the responsibility of medication administration
clearly retained by the nurse responsible for caring
for the patient?. (Y: 0) (N: 1)
15. How often are drugs prepared before they are
required? (Sometimes: 2) (Never: 0).
So you think you are a safe drug
giver?
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16. Are drug errors an acceptable risk? (Y: 2) (N: 0)
17. How often do you and your colleague calculate
the dose independently before comparing answers?
(Always: 0) (Sometimes: 1)
18. How often do you rely on your colleague to make
the correct calculation instead of working it out
yourself? (Sometimes: 2) (Never: 0)
19. How often do you and your colleague go together
to identify the patient? (Always:0 ) (Never: 2)
20. How often do you check the dosage in the
formulary when you are not sure?
(Always: 0) (Never: 2)
Scores
 If you have scored between 0-5
Very well done: on the whole your drug administration
practice is very safe and you are an excellent role model
for colleagues, share your good practice
Scores
 If you have scored between 6-15
Be extra careful: your practice is not consistent, you should
brush up on your technique before you make an error.
Make sure you are familiar with the drug policy and look
at techniques to avoid errors.
Scores
 If you have scored between 16-37
This should ring alarm bells!! Your practice is really rather
dangerous and your competence to administer drugs is
questionable, seek help, pull your socks up!
Medication Errors
 The medication administration observational
audit highlighted several issues including
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Inadequate space
Distractions
Interruptions
Staff shortages
Large range of drugs and doses used in some areas
Similar packaging of drugs
Tiredness as a result of long shifts
Medication Errors
– Some patients did not have identification bracelets
– Inadequate checking of identification labels
– One nurse checking two different prescriptions at the
same time
– Second checker not checking the entire process
– Checking prescriptions and medications very quickly
– Calculations not being made independently by both
nurses
Medication Errors
What percentage of incidents are reported
by nursing staff?
Medication Errors
What percentage of incidents are reported
by nursing staff?
95% of all medication related incidents are
reported by nursing staff.
Medication Errors
What percentage of all reported incidents
relate to medication errors?
Medication Errors
What percentage of all reported incidents
relate to medication errors?
In 2003-2004 19% of all reported incidents
relate to medication errors
Medication Errors
53% of all reported drug errors can be
categorised as nurse checking errors.
Medication Errors
What percentage of incidents are graded as
being of moderate or high significance?
Medication Errors
What percentage of incidents are graded as
being of moderate or high significance?
Approximately 22% are graded as orange
or red which is equivalent to 24 incidents
per year or 2 incidents every month.
Medication Errors
 Incident reporting is an important element of risk
management.
 Reporting of adverse events and near misses
allows systems errors to be detected.
 Review and implementation of new systems can
prevent errors from re-occurring and near miss
incidents becoming adverse events.
Medication Errors
Activity
Imagine that you are the Clinical Governance
Facilitator.
– Working in small groups read the following incident
reports.
– What other information do you need to decide how to
proceed with this form?
 Grade the incident using the grading matrix.
 What recommendations would you make to
prevent this from re-occurring?
Example Medication Errors
“IV Morphine given by *** and checked by
***. Dose given was too much.”
Example Medication Errors
“At 20.30 I gave *** a 400 mls fluid bolus
because she had not passed urine since
11.00 that morning when her catheter was
removed. I forgot to set the volume limit
and she got 540 mls.”
Example Medication Errors
“Frusemide IV infusion made up with 5%
Dextrose due to patient having a high
serum sodium. When changing infusion
22 hours later discovered that Frusemide
is not compatible with Dextrose.”
Final Message to take home
Do’s and Don’ts
 Do be careful and allow sufficient time
 Don’t allow yourself to be distracted or
rushed
 Don’t “short cut” the checking process
 Do check with the Dr/Pharmacist if unsure
and question colleagues however senior to
you if you don’t agree
 Do check that the correct patient receives
the correct dose of the correct medication at
the correct time, via the correct route.
Final Message to take home
Do’s and Don’ts
Do report incidents and ‘near
misses’