ERROR IN MEDICATION.pptx

Nursing Syllabus

1. INTRODUCTION A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

2. Such events may be related Professional practice Health care products Procedures and systems Product labeling, packaging. Administration Education Monitoring etc.

3. TYPES OF MEDICATION ERRORS Medication errors can occur anywhere along the route, from the clinician who prescribes the medication to the healthcare professional who administers the medication.

4. TYPES OF MEDICATION ERROR Prescribing error Omission error Wrong time error Improper dosing error Wrong dose error Wrong route error Wrong drug preparation Lack or communication error

5. 1. Prescribing error Prescribing errors, wherein the selection of a drug is incorrect based on the patient's allergies or other indications. Additionally , the wrong dose, form, quantity, route (oral vs intravenous), concentration, or rate of admission could be used.

6. 2. Omission error Omission errors, in which there is a failure to give a medication dose before the next one is scheduled.

7. 3. Wrong time errors Wrong time errors, wherein a medication is given outside the predetermined interval from its scheduled time.

8. 4 . Improper dosing error Improper dosing errors, wherein a greater or lesser amount of a medication is delivered than is required to manage the patient's condition.

9. 5. Wrong dose error Wrong dose errors, wherein the correct dosage was prescribed, but the wrong dose was administered.

10. 6. Wrong route error Improper administration technique errors , such as administering a medication intravenously instead of orally.

11. 7. Wrong drug preparation Wrong drug preparation errors, wherein a medication is incorrectly formulated ( i.e. too much or too little diluting solution added when a medication is reconstituted).

12. 8. Lack or communication error Fragmented care errors, wherein a lack of communication exists between the prescribing physician and other healthcare professionals.

13. CUASE OF MEDICATION ERRORS Distraction Environment Lack of knowledge/Understanding Incomplete patient information Memory Lapse Systemic problem

14. Distraction A nurse who is distracted may read "diazepam" as "diltiazem .“ The outcome is not insignificant-if diazepam is accidentally administered, it could sedate the patient, or worse ( e.g ., if the patient has an allergy to the drug).

15. Environment A nurse who is chronically overworked can make medication errors out of exhaustion. Additionally , lack of proper lighting , heat/cold , and other environmental factors can cause distractions that lead to errors .

16. Lack of knowledge/Understanding Nurse who lack complete knowledge about how a drug works,its various name ( generic,brand name), its side effects, its contraindication, etc can make errors.

17. Incomplete patient information Lacking information about which medications a patient is allergic to, other medication the patient is taking, previous diagnosis, or current lab results can all lead to errors. Nurses who aren't sure should always ask the physician or crosscheck with another nurse.

18. Memory Lapse A nurse may know that a patient is allergic, but forget. This is often caused by distractions. Forgetting to specify a maximum daily dose for an "as required" drug is another example of a memory-based error.

19. Systemic problem Medications that aren't properly labelled , medications with similar names placed in close proximity to one another, lack of bar code scanning system, and other issues can lead to medical errors.

20. Preventing Medication Errors

21. Know the patient This includes the patient's name, age, date of birth, weight, vital signs, allergies, diagnosis, and current lab results. Avoid shortcuts.

22. Know the drug Nurses need access to accurate, current, readily available drug information, whether the information comes from computerized drug information systems, order sets, text references, or patient profiles. If you have any questions or concerns about a drug, don't ignore your instincts-ask. Remember that you are still culpable, even if the physician prescribed the wrong medication, the wrong dose, the wrong frequency, etc.

23. Keep line of communication open Breakdowns in communication among physicians, nurses, pharmacists, and others in the healthcare system can lead to medication errors.

24. Document each drug administered Accurate documentation is essential and should include accurate recording of the drug information, the name of the drug, the dose, route, time, patient response, and any refusal of the drug by the patient.

25. Take an active role in correcting issues you identify EXAMPLE- If you see that look-alike or sound-alike (LASA) medications are stored next to each other, ask your supervisor to correct the problem, emphasizing the increased risk of medication errors.

26. Consequences of errors Medication errors can have serious and costly consequences, such as increased patient lengths of stay, additional medical interventions, serious harm, or even death .

27. CARE OF MEDICINE AND MEDICINE CUPBOARD

28. CARE OF MEDICINE AND MEDICINE CUPBOARD All the medicines and drugs must be checked as they are received from the dispensary . Dangerous drugs are given by special order and every dose should be accurate . Medicine cupboard should be kept in room, near to the ward .

29. All high alert drugs must be kept separately in a separate cupboard and it must be kept locked and the keys should be with ward sister. Medicine for external use should be kept in a separate part of the cupboard.   The cupboard should be kept in well lighted and high alert drugs should be clearly labelled. CARE OF MEDICINE AND MEDICINE CUPBOARD

30.   There should be separate compartment for mixture, tablets, powders, etc. The container should be arranged alphabetically so that it is easy to find them A register should be maintained to keep the account of the dangerous drugs. CARE OF MEDICINE AND MEDICINE CUPBOARD

31.   Check the expiry date of every drug and make use of it before its expiry date . Emergency drugs should be kept in a place where they are easily obtained for emergency use. CARE OF MEDICINE AND MEDICINE CUPBOARD

32. NARCOTIC DRUGS The nurse must know the law about the use of narcotics drugs. These drugs should be kept in a separate cupboard and locked. The key should be with the ward senior or senior nurse incharge on duty. A special register should be maintained for narcotic drugs. Proper documentation should be done about the patient, nurse, doctor who ordered narcotic drug and dosage. The narcotic drug should be stocked only person/institution who have licensed to do so.