Transcript Preventing Medication Errors

The Center For Life Enrichment
October 2009
PREVENTING MEDICATION
ERRORS
THE PROBLEM
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Medication errors can occur:
between brand names, generic names, and brand- togeneric names like Toradol and tramadol.
abbreviations, acronyms, dose designations, and other
symbols used in medication prescribing also have the
potential for causing problems.
illegible handwriting,
unfamiliarity with drug names,
newly available products
similar packaging or labeling,
incorrect selection of a similar name from a
computerized product list,
communicated verbally,
FOR EXAMPLE….
Several errors have occurred involving mix-ups with
the oral diabetes drug Avandia and the anticoagulant
Coumadin. Although they don’t look similar when
typed or printed, the names have been confused with
each other when poorly written in cursive. The first
letter “A” in Avandia, if nor fully formed, can look like a
“C”, and the final “a” has appeared to be an “n”.
Another example is, the abbreviation “D/C” means
both “discharge” and “discontinue”. The National
Coordination Council for Medication Errors Reporting
and Prevention (NCCMERP) notes that patients’
medications have been stopped prematurely when D/Cindented to mean discharged was misinterpreted as
discontinue because it was followed by a list of drugs.
WHAT IS A “MAR”?
MAR stands for Medication Administering Record
It is a record of medications given daily to a client
for any reason.
On the front of the MAR you will find:
•Client’s name
•List of medications with dose instructions
•Name of their Physician
•Any known allergies
•An area to initial each day that you give the medication
On the back of the MAR you will find:
•An area to fill out why PRN (as needed medicines) were
given
•An area to explain any mistakes that were made (wrong
time, medication, dose…)
•An area to explain any omissions or changes(client was not
here, there was no medication, the doctor called the nurse
with different instructions …)
•A place to have a record of your initial along with your
name
“TO ALL CMTS”
This kindly reminder is in the nurse’s office located by the sign off
board and will help you fill out the MAR.
 On weekends and on days that the Center is Closed put a slash in the
appropriate box on the MAR
 Under omission write an explanation (Center Closed meds given out at
home)
 When the Center is open and the Client does not come in or goes home
before the medication should have been given– put a circle with your
initials on the MAR and write on the back under omission the
explanation
 Write the bubble number you use on the blister pack on the MAR under
your initials.
 Controlled meds will be counted at the end of the day by 2 CMTs and
documented on the Control Sheet.
 Outings- all meds checked out of the building must be in “double”
locked box
 Meds removed by home staff, must sign meds out and back in
LOW RISK MEDICATION ERRORS
Using write-out or erase a mistake
 Failure to initial administered medications
 Failure to document reason/ results for PRN
medication administration on the back of MAR
 MAR block circled without an explanation on the
back of the MAR
 Failure of include a start date for a prescribed
medication on the MAR
 Failure to fill out clients information at the
bottom of the MAR
 Any other medication error not mentioned which
does not result in harm to the client
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HIGH RISK MEDICATION ERRORS
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Failure to administer any prescribed medication without
instruction from the nurse to do so.
Administration of the incorrect medication
Administration of medication at the incorrect time without the
permission of the nurse
Medication administered to the client via the wrong route (
mouth, g-tube, topical)
Administration of a dose of medication other than that which has
been ordered
Administration of an expired medication
Administration of a medication to which a client is allergic, when
the allergy is documented on the MAR
Failure to give medication for that day
Any other medication error not mentioned which could potentially
result in harm to the clinet
Common Causes of Medication Error
Medical Errors
48,000 to 98,000 people die each year as a result of
preventable medical error
Physician Order Entry
39%
Administration 38%
Pharmacy Dispensing
11%
Order Transcript 12%
6 BASIC TYPES
OF ADMINISTRATION ERRORS
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Error of Omission
Error of Commission
Incorrect Dose Preparation Error
Incorrect Administration Technique
Deterioration Error
Unordered or Extra Dose Medication Error
REVIEW OF COMMON MISTAKES
Not remembering your consumers who take daily
meds.
 Not filling the MAR out entirely
 Not writing the bubble number (if applicable)
 Waiting until the client has 3 days of meds left
 Not signing the back of the MAR
 Not writing an Omission on the back of the MAR
 Not giving the med at the scheduled time
 Rushing at the end of the day to give meds
 One-on-ones need to delegate their responsibility
of giving meds should they leave for the day
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SOME HELPFUL THINGS WE CAN DO
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Only one person at a time in the nurses office
Ask the nurse any questions or concerns
Letting the nurse know when a mistake has been
made. It is better to acknowledge a mistake right
away. No one is perfect, we all have days when things
don’t go right.
Even for staff who are not med-certified, they are still
responsible to make sure the clients in their room
have received their medication before they leave for
the day. One way to make sure this doesn’t happen is
creating a check list for your individuals so at the end
of the day you can check the list to make sure all their
needs are met before they leave.
BEING ACCOUNTABLE FOR YOUR MISTAKES
CMT’s will be written up for the following offences.
After 3 offences the CMT will be suspended from
giving meds until a review is scheduled.
Not bringing in a client to receive their meds
Not filling out the MAR completely
Not following the procedure for dispensing
“controlled meds”
Not signing meds out on the “check-out” sheet
when going on an outing
Not sending medicine renewal sheet home when
there’s 3 days left of a medication
7 RIGHTS
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The right individual
The right medication
The right dose (E.g. 1mg, vs.. 3mg …. )
The right time that the medication is to be
given
The right route (E.g. mouth vs. topical…)
The fight form (E.g. liquid, pill, powder ….)
The right documentation
HOW TO DISPOSE
Guidelines for Drug Disposal
 Do not flush prescription drugs down the toilet unless this information
specifically instructs you to do so.
 If no instructions are given, throw the drugs in the household trash, but first:
 Take them out of their original containers and mix them with an
undesirable substance, such as used coffee grounds or kitty litter. The
medication will be less appealing to children and pets, and unrecognizable
to people who may intentionally go through your trash.
 Put them in a sealable bag, empty can, or other container to prevent the
medication from leaking or breaking out of a garbage bag.
 Take advantage of community drug take-back programs
 Before throwing out a medicine container, scratch out all identifying
information on the prescription label to make it unreadable. This will help
protect your identity and the privacy of your personal health information.
 Do not give medications to friends. Doctors prescribe drugs based on a person's
specific symptoms and medical history. A drug that works for you could be
dangerous for someone else.
 When in doubt about proper disposal, talk to your pharmacist
http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm
IMPORTANT THINGS TO REMEMBER….
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A three way check is used to ensure you give the
medication in a safe and secure manor, by
checking 3 things the
MAR
 Doctors Orders,
 Pharmacy Label
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Checking the bottle at least 3 times ensures you
have the
right person
 right medication
 right route
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TO REMEMBER…..
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Many medications come in Generic form. Checking
the generic with the brand is very important to make
sure you have the right medication.
When disposing expired meds remember to mix it
with something undesirable and place it in a plastic
baggy before dumping it in the trash.
At times when a new medication is started their
maybe some mild side affects such as lightheadedness
or nausea that disappear after a short while
Consumers who attend TCLE that self-medicate
will have to meet with the nurse to ensure they are
taking the medication in a safe manor. Direct Care
Staff will then monitor them while they take their
medication to ensure it is taken safely.
ALSO TO REMEMBER….
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TCLE and the DDA require you to be med-certified if
you are administering medications to our consumers
When a consumer goes on an outing their medication
is to be double locked in their box or blue bag and
locked in the car
Some consumers take medication that is considered a
narcotic. All narcotics and a few other medications
are controlled by the state to ensure that the
medication is monitored and counted daily.
Any medication that is Expired should NOT be
given to a consumer. If you come across an expired
drug notify the nurse and caregiver.
Name:____________
QUIZ
1.You should check the medicine bottle at least 3 times before giving the med.
True or False: _________________________________
2. Generic medications and Brand name medications can have names that are very similar, so it would be easy to give the
wrong medicine. How would you know you are giving the right medicine to the right person, list 3 things you should do prior
to giving the medication.
•_________________________________________________
•_________________________________________________
•_________________________________________________
3. What is the best way to dispose of medication?
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4. When you are aware a client is taking a new medication there may be some side affects, such as light-headedness or
stomach upset this is normal.
True or False: _________________________________
5. Clients who are self-mediators take their own medications. The direct care staff should monitor them.
True or False: _________________________
6. Becoming a CMT is mandatory by the DDA and TCLE if you are administering medications to our consumers?
True or False: ___________________________
7. When on an outing with clients who take medications, where do you keep the medications?
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8. What consist of the 3-way check when giving a medication, list the 3 things:
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9. A controlled medication is a medication such as a narcotic, why is it called controlled?
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10. You’re about to give a medication and see that it is expired, what should you do?
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