Transcript Quarterly Medication Error Data

Quarterly Medication Error
Data
January 2006
Quarterly Error Report
Medication Error data based upon Safety Reports
No report = No data
Greater than 51% of RN’s report they have made
a medication error in the past 12 months.*
Only 5% of significant errors are reported. *
Reports are completed*
Error is life-threatening
Medication Vital to Patient’s Treatment
*Lowe, Debra K and Belchre, Jan V. 2002. Reporting medication Errors Through
Computerized Medication Administration. CIN: Computers, Informatics
Nursing. 20:5. 178-183.
Error Stage
for Serious Medication Errors
Administer
Ordering
38%
39%
eMAR
OE
Dispensing
11%
Transcription
12%
Leape, JAMA
1995
Quarterly Error Report
10/2005 – 12/2005
Ordering: 20 (11%)
Dispensing: 10
(5.5%)
Administration: 144
(83%)
Total: 174
Ordering
Dispensing
Administration
Emerging Themes
eMAR
System only as good as the user that drives it.
Team double-checks not being performed
Physician and Nurse check patients’ allergies
Pharmacist default Times of First Dose not verified /
corrected
Time of Next Dose not verified
By passing Reconciliation Prompt
Not documenting pain medication
administrations
Top Nine
Wrong Frequency
60
51
Pump Programming
50
Ordering
40
Wrong Dose
24
30
20
20
Wrong Med
17
10
20
10
8
Dispensing
5
4
Other
No allergy order
0
1st Qtr
Communication
Medication Errors
Two nurses double-checked
red syringe of chemotherapy then
placed syringe in refrigerator.
Nurse came back and retrieved red
syringe from refrigerator and
administered med to patient.
Patient received wrong drug.
Medication Error
Medication order written
for Toradol with instructions not to give
the med until 10pm.
Instructions not read by nurse.
Patient received Toradol against
instructions.
Two incidences
Medication
Errors
Patient ordered for Fentanyl 0 – 100
mcg / hour continuous infusion.
Flow sheet indicated patient received
2.5 mL/hr = 25 mcg/hr.
Pump programmed for 25 mL/hr = 250
mcg/hr.
Patient bradycardic
Medication Error
Bypassed
verification of
medication
removed from
Omnicell.
Nurse intended to
retrieve Haldol
from Omnicell.
Medication Error
Ommicell drawer contains
both Haldol and Lasix.
Removed Lasix from
drawer.
Administered wrong
medication (Lasix) to
patient IVP.
Questions?
Please email Carol Luppi
[email protected]