Medication error

1. Click to edit Master subtitle style
1/20/15
Medication errors & safe medication practices
any incorrect or wrongful administration of a medication,
such as
a mistake in dosage
or route of administration,
failure to prescribe
or administer the correct drug
or formulation for a particular disease

2. 1/20/15
Medication errors & safe medication practices
•or condition, use of outdated drugs,
• failure to observe the correct time for
administration of the drug,
• or lack of awareness of adverse effects of
certain drug combinations.
• Causes of medication error may include
difficulty in reading handwritten orders,
•confusion about different drugs with similar
names,
•and lack of information about a patient's
drug allergies or sensitivities.
• When the nurse is in doubt, administration
of a drug should be delayed until specifically
authorized by a physician.

3. 1/20/15
Medication errors & safe medication practices
•POLICY AND PROCEDURE FOR
ADMINISTRATION OF MEDICATIONS:
AIM: To provide uniform guidelines for
administering and charting of medications and
•treatments.
•RATIONALE: Nurses
administer medications as
part of everyday practice
and there is a potential
for
• errors to
occur ,to avoid such
errors, medication
administeration guidelines
are necessary.
•PERSONNEL
RESPONSIBLE :
Physicians / Surgeons
•
Nurses
•All Nursing Personnel
should follow the
following
• The “Five Cs/Rs”:
•Correct/Right
Patient/Child
•Correct/Right Medicine
•Correct/Right Dose
•Correct/Right Time
•Correct/Right Route

4. 1/20/15
Medication errors & safe medication practices
Always Wash hands before and after
administration of any form of medications and
between patients.
•Identify the correct patient and confirm their
identity before giving the medication
•Check the drug at the site of preparation
(eg:medication trolley) along with
dosage,expiry of drug etc. Again recheck this
information at patients bedside before
administering the drug.
•Ensure any preliminary checks and
observations have been carried out if
necessary prior to administration (e.g. blood
pressure monitoring prior to administration
of anti-hypertensives).
•Check if the patient has any known allergy or
contra-indication to the prescribed
medication even if none are documented ).
Inform the prescribing practitioner
immediately if the patient does and do not
give the medicine.
•If more than one medicine is prescribed,
check for compatibilities and drug
interactions If they are not compatible,
inform the prescribing practitioner.

5. 1/20/15
Medication errors & safe medication practices
•If patient is conscious explain procedure to the patient
(Eg:" im going to give you an injection...)
Try as much as possible not to bring pain or discomfort to
patient during administeration of medication (no
harsh,jerky movements)
Monitor the effects of the medicine administered and document
in the nursing records
•Incase of any
Medication errors,
incident should be
reported
immediately and
action should be
taken
•Incase of any
adverse drug
reactions or adverse
drug event, stop
medication
immediately, Inform
doctor on duty
immediately and
administer
prescribed antidote,
treatment as soon
as possible to
releive the
situation.Report
incident.

6. 1/20/15
•Incase a prescribed drug is discontinued,
write "DISCONTINUED" in red pen along
with the date and hand over to other
nurses,make sure physicians orders are
followed.
•Always write correct drug name with correct
dosage on prescription pad and date on
prescription pad.
•Never miss time to give drug,if drug is not
given on time ,strictly do not give double
dose. write "not given" in medication
chart/register and explain the reason of not
giving during handover.
•If medication is prepared and part of the dose
is to be given later,the medication will be
labeled with -"name of drug,dilution and
dosage"

7. 1/20/15
Medication errors & safe medication practices
•Identify the correct patient and confirm their
identity before giving the medication
Check the drug at the site of preparation
(eg:medication trolley) along with dosage,expiry
of drug etc. Again recheck this information at
patients bedside before administering the drug.
•Ensure any preliminary checks and
observations have been carried out if
necessary prior to administration (e.g. blood
pressure monitoring prior to administration of
anti-hypertensives).
•Check if the patient has any known allergy or
contra-indication to the prescribed
medication even if none are documented ).
Inform the prescribing practitioner
immediately if the patient does and do not
give the medicine.
•If more than one medicine is prescribed, check
for compatibilities and drug interactions If
they are not compatible, inform the
prescribing practitioner.
•Check if it is necessary for the medication to
be given before or after food/fluid
•If patient is conscious explain procedure to
the patient (Eg:" im going to give you an
injection...)
•Try as much as possible not to bring pain or
discomfort to patient during administeration
of medication (no harsh,jerky movements)
•Monitor the effects of the medicine
administered and document in the nursing
records
•Incase of any Medication errors, incident
should be reported immediately and action
should be taken
•Incase of any adverse drug reactions or
adverse drug event, stop medication
immediately, Inform doctor on duty
immediately and administer prescribed
antidote, treatment as soon as possible to
releive the situation.Report incident.
•Incase a prescribed drug is discontinued, write
"DISCONTINUED" in red pen along with the
date and hand over to other nurses,make sure
physicians orders are followed.
•Always write correct drug name with correct
dosage on prescription pad and date on
prescription pad.

8. 1/20/15
Medication errors & safe medication practices
•Correct/Right Documentation (new 6th right added)
•
•ORAL MEDICATIONS
•DO NOT leave the medication in a room for
the patient caregiver to administer later
•Strictly adhere to instructions of
tablet/capsule to be given.(eg_can it be
crushed?dissolve?)
•INTRAVENUOS INJECTIONS:
•Check solution for sediments, crystalizations
•Check for thrombosis/ patency of cannula.
•Aways flush cannula, before and after
administering IV injections.
•Check and Re-check correct dilution of drug.if
after loading injection, drug appears Milky,
discoloured.DO NOT administer.
•If an injection is to be given slow IV, please
ensure that it is pushed slowly (over a
minimum time of 2 minutes) or infusion pump
is used.
•INTRAMUSCULAR INJECTIONS:
•Make sure correct site is identified.
•Swab site with spirit before giving injection.
•Make sure needle is in the muscle
•SUBCUTANEOUS INJECTIONS:
•Make sure correct site is identified (in case of
rotatating sites also)
•swab site with spirit before giving the
injection
•Do not rub area after giving injection..
•ALWAYS CHECK FOR REACTIONS TO
MEDICATION DURING AND AFTER GIVING THE
INJECTION.
•-------------------------------------------------------------
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9. 1/20/15
Medication errors & safe medication practices
•Correct/Right Documentation (new 6th right added)
•
•ORAL MEDICATIONS
•DO NOT leave the medication in a room for
the patient caregiver to administer later
•Strictly adhere to instructions of
tablet/capsule to be given.(eg_can it be
crushed?dissolve?)
•INTRAVENUOS INJECTIONS:
•Check solution for sediments, crystalizations
•Check for thrombosis/ patency of cannula.
•Aways flush cannula, before and after
administering IV injections.
•Check and Re-check correct dilution of drug.if
after loading injection, drug appears Milky,
discoloured.DO NOT administer.
•If an injection is to be given slow IV, please
ensure that it is pushed slowly (over a
minimum time of 2 minutes) or infusion pump
is used.
•INTRAMUSCULAR INJECTIONS:
•Make sure correct site is identified.
•Swab site with spirit before giving injection.
•Make sure needle is in the muscle
•SUBCUTANEOUS INJECTIONS:
•Make sure correct site is identified (in case of
rotatating sites also)
•swab site with spirit before giving the
injection
•Do not rub area after giving injection..
•ALWAYS CHECK FOR REACTIONS TO
MEDICATION DURING AND AFTER GIVING THE
INJECTION.

10. 1/20/15
Medication errors & safe medication practices
•Aim:To ensure that IDS Pharmacy Staff handle
drug recalls consistently.
Rationale: to prevent wrong drug and adverse
drug reaction.
Procedure:
MEDICATION MUST BE OF THE HIGHEST
QUALITY:Only medication of highest quality
dispensed from the Pharmacy. Any drug of
compromised or questionable quality shall be
immediately removed from inventory with
proper documentation, and the
pharmacysoftware will be updated to reflect
such removal.
DRUG RECALL NOTIFICATIONS: Hospital will
obtain notification of drug recalls from a
variety of sources including: trial sponsors,
pharmaceutical manufacturers and
pharmaceutical
distributors. Sometimes, internally observed
problems may lead the Director to
determine that a certain drug dose has been
contaminated, or possibly contaminated, and
should be removed from inventory;
EXTERNAL NOTIFICATIONS BUT NO EXISTING
INVENTORY: Whenever an external recall
notification is received by pharmacy, Staff will
determine if the product was ever received as
well
as the quantity on hand, if any. If the product
was never received, or if inventory has been
depleted, the recall procedure is complete;
EXTERNAL NOTIFICATIONS WITH EXISTING
INVENTORY: If the recalled product was
received, and if any inventory remains at
pharmacy, it will be documented on the
pharmacy log book and inventory shall be
segregated from the rest of the stock until the
entity making the
recall notification advises pharmacy to return
or destroy the product;
IF NECESSARY, REFER TO MEDICATION
ERRORS POLICY: If drug has been destroyed
or
compromised by Hope Staff, please refer to
the separate policy entitled “Medication
Errors;”

11. 1/20/15
Medication errors & safe medication practices
•Aim: this policy is to describe the Medication
Error Reporting procedure.
Rationale: To prevent risks associated with
the therapeutic
•use of medications.
•Appropriate identification of an error and the
documentation, assessment of medication
errors and trend analysis, education, and
improvement in systems, medication errors
can be minimized
•To insure that the medication process is safe.
•
Medication Error: 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. A
medication error can be a mistake in any step
of the
medication management process or system
(e.g. selecting, prescribing, administering or
monitoring), regardless of the causes and
regardless of whether or not the error reaches
the patient.
Procedure:
1.Medications shall be properly prescribed,
dispensed, and administered in accordance
with the Medical Center, Department of
Nursing, Department of Pharmacy polices
and procedures, and patient “Rights” (Right
patient, Right medication, Right dose,
Right time, Right route/administration
technique, and Right monitoring).
2.All errors or events associated with the
medication system or a step in the medication
process shall be reported using an incident
report, whether or not the error reached
the patient.
3.Physicians, or the appropriate prescriber,
must be notified as soon as reasonable of
medication errors that have reached the
patient when:The errors are deemed to be
clinically significant, and/or
•Involve medications that are not administered
as ordered. Examples include

12. 1/20/15
Medication errors & safe medication practices
•If patient is conscious explain procedure to
the patient (Eg:" im going to give you an
injection...)
Try as much as possible not to bring pain or
discomfort to patient during administeration of
medication (no harsh,jerky movements)
•Monitor the effects of the medicine
administered and document in the nursing
records
•Incase of any Medication errors, incident
should be reported immediately and action
should be taken
•Incase of any adverse drug reactions or
adverse drug event, stop medication
immediately, Inform doctor on duty
immediately and administer prescribed
antidote, treatment as soon as possible to
releive the situation.Report incident.

13. 1/20/15
Medication errors & safe medication practices
•before giving any high risk medication,verify
with the doctor on duty.
Only prescribe medications as per doctors
written orders,make sure documented orders
are signed by doctor with correct date and
name.
•Written orders for medications chould be
clear and legible.

14. 1/20/15
Medication errors & safe medication practices
•Never miss time to give drug,if drug is not
given on time ,strictly do not give double
dose. write "not given" in medication
chart/register and explain the reason of not
giving during handover.
•If medication is prepared and part of the dose
is to be given later,the medication will be
labeled with -"name of drug,dilution and
dosage"
•before giving any high risk medication,verify
with the doctor on duty.
•Only prescribe medications as per doctors
written orders,make sure documented orders
are signed by doctor with correct date and
name.
•Written orders for medications chould be
clear and legible.

15. 1/20/15
Medication errors & safe medication practices
•wrong dose, wrong route, omitted dose, extra dose, medications ordered
to be
given STAT/NOW that are given late, and medications not given at the
ordered
time interval, e.g., ordered every 6 hours and given
late.Physician/prescriber notification must be documented in the medical
record using
•the Provider Contact Note (Ucare) or other appropriate note.
Reporting
Medication errors will be reported using the Incident Reporting form
according Incident ReportingPolicy ref ( )
It includesName of the Medication involved
•Type of error
•
E.g. extra dose, improper dose/quantity,
omission, wrong administration
•technique, wrong dosage form, wrong drug,
wrong preparation, wrong patient,
•wrong route, wrong time, other (specify).
•Initial Node of the error
•Where in the medication process did the
initial error occur? For example,
•prescribing, transcribing, dispensing,
administering or monitoring.

16. 1/20/15
Medication errors & safe medication practices
•Examples of Errors
Prescribing: Illegible handwriting or unclear orders
Non-compliance with order-writing guidelines
Wrong order form used
Therapeutically incorrect orders
Decimal point errors
Documenting -Improper therapeutic screening of order at time of taking
order off by nursing or pharmacy (dose, allergy check)
Incorrect/incomplete transcription of order on MAR or Kardex
Not transcribed onto MAR or Kardex
Pharmacy transcription error
Incorrect documentation of medication administered
Dispensing -Medication not available due to
delays in sending order,
faxing order, processing order, delivery from
pharmacy to unit, delivery
to wrong place/unit, unknown delay
Incorrectly dispensed/reconstituted/labeled
by pharmacy
Incorrectly diluted/reconstituted/labeled by
nursing
Incorrectly stocked in Pyxis by pharmacy
Incorrectly accessed in Pyxis

17. 1/20/15
Medication errors & safe medication practices
•Check if it is necessary for the medication to
be given before or after food/fluid
•Written orders for medications should be
clear and legible.