Transcript medication error

Focus on
PHARMACOLOGY
ESSENTIALS FOR HEALTH PROFESSIONALS
CHAPTER
8
Medication Errors
and Prevention
Introduction
• Medication and medical errors occur
throughout the United States.
• The system needs to be improved to
afford patients with true quality care.
• Health professionals, patients, and
families must work together and
become educated about reducing all
types of medical errors.
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Medication Errors
• A medication error is the
inappropriate or incorrect
administration of a drug that should be
preventable through effective system
controls.
• Medication errors result in pain, injury,
and death.
• Medication errors usually occur more
frequently than they are reported.
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The First Stage of Medication
Errors
• Prescribing or ordering medication
– Errors are most prevalent when:
 Choosing a medication
 Choosing its dosage
 Choosing its schedule
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The Second Stage of Medication
Errors
• Dispensing of medication
– It is important to double-check medications
against:
 A medication administration record (MAR)
 Another medication order
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
Jahangir Moini
The Third Stage of Medication
Errors
• Administration of medication and
patient monitoring
• These are the responsibilities of the
health care professional.
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Additional Information
• The most common medication error
concerns dosage
• Increased use of OTC drugs and herbals
contribute to medication errors
• Medication errors must be reported as
soon as they are noticed
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
Jahangir Moini
Kasco Sandor / Shutterstock
Figure 8-1
Nearly half of fatal medication errors occur in patients older than 60 years
of age.
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Why Medication Errors Occur
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•
•
•
•
•
Use of incorrect abbreviations
Miscommunication
Missing information
Lack of appropriate labeling
Environmental factors
Poor management
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Causes of Medication Errors
•
•
•
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Wrong patient
Incorrect route
Incorrect drug
Incorrect dose
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Causes of Medication Errors
• Incorrect time
• Incorrect technique
• Incorrect information on the patient
chart
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Reducing Medication Errors
• Employ an adequate number of staff
• Use standardized measurement
systems
• Use error-tracking systems
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Reducing Medication Errors
• Review of original drug orders
• Compile medication profiles
• Provide suitable work environments
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Reducing Errors in Health Care
Facilities
• Automation allows drug storage
cabinets to maintain an accurate
inventory.
• Risk management departments
minimize errors and examine risks.
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Reducing Errors in
Health Care Facilities
• Avoid:
– Expired medications
– Transfer of medications between containers
– Overstocking
– Dangerous abbreviations
– Reference materials that are not up to date
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Results of Medication Errors
• In hospitals, medication errors are the
most common causes of morbidity and
preventable death.
• Also, financial penalties may be
assessed, and legal actions may result.
• Thorough investigation and
documentation lead to prevention of
future errors.
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Reporting Medication Errors
• Health care professionals should use
the FDA’s MedWatch program to report
medication errors.
• Other related organizations include:
– National Coordination Council for
Medication Error Reporting and Preventing
(NCC MERP)
– Institute for Safe Medication Practices
(ISMP)
– The Joint Commission
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Documenting Medication Errors
• The patient’s medical record should be
updated with complete information
about medication errors.
• Incident reports (occurrence reports)
should also be completed for risk
management.
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Documenting Medication Errors
• Root cause analysis of documentation
may be used to prevent future errors
from occurring and to reduce potential
risks.
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Strategies
• Assessment of patients’ use and
knowledge of medications
• Planning of medication therapy and
understanding of every step that will
occur
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Strategies
• Implementation of all proper
procedures to ensure accurate use and
monitoring
• Evaluation of correct outcomes and
adverse effects
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Categories of Medication Errors
• A – having capacity to cause errors
• B – occurred errors that did not reach
patient
• C – errors that reached patient without
harm
• D – errors that could have caused harm
• E – errors that might have caused harm
and required intervention
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Categories of Medication Errors
• F – errors that might have caused harm
and required hospitalization
• G – errors that might have caused
long-term harm
• H – errors that required intervention to
sustain life
• I – errors that might have caused the
patient’s death
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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Reconciliation of Medications
• Polypharmacy is receiving multiple
medications, sometimes for the same
condition, that have conflicting actions
• It is most common in older patients
• Keeping track of patient medications as
health care providers are changed is
called medication reconciliation
Focus on Pharmacology: Essentials for Health Professionals, Second Edition
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