medicationerror-130822005215-phpapp02.pptx

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1. MEDICATION ERROR and near misses reporting and analysis ph-01-007 PREPARED BY : Ayesa Gatdula and Jeffritz Paltu-ob

2. DEFINITON Medication errors, broadly defined as any error in the prescribing, dispensing, or administration of a drug, irrespective of whether such errors lead to adverse consequences or not, are the single most preventable cause of patient Harm. A medication error is any preventable event that may cause or lead to inappropriate medication use or client harm while the medication is in control of health care professional client or consumers.

3. CLASSIFICATION OF MEDICATION ERROR

4. CLASSIFICATION OF MEDICATION ERROR PRESCRIBING / ORDERING ERRORS: Inappropriate selection of drugs (based on indication, contraindications, known allergies, existing drug therapy, and other factors. Inappropriate dose, dosage form, concentration, frequency, duration, route of administration, rate of administration and/or instruction for use Inappropriate Verbal / telephone order Incomplete order, illegible order or use of prohibited abbreviations. Patient ID Error: Error in patient name or file number.

5. PRESCRIBING ERRORS

6. CLASSIFICATION OF MEDICATION ERROR Transcription Errors: - Involves both the orders that are manually transcribed onto manual record ( e.g medication administration record (MAR) and electronically transcribed into computer systems ( eMAR ).

7. CLASSIFICATION OF MEDICATION ERROR Administration Errors: Patient ID Error: Error in patient name or file number. Omission Error: the failure to dispense or administer an ordered dose to a patient by the time the next dose is due, assuming there has been no prescribing error. Wrong Medication Error: the administration of medication to a patient other than that ordered by the physician.

8. CLASSIFICATION OF MEDICATION ERROR Administration Errors: Wrong Route Error: the administration of a medication to a patient by the route other than that ordered by the physician or doses administered via the correct route but at the wrong site (e.g., left eye instead of right eye) Wrong Dose Error: includes administration of overdose, under-dose, or extra dose. Administration of a drug that has expired or for which the physical or chemical dosage form integrity has been compromised.

9. Medication Error Severity Classification based on the outcome to patient Category A - Circumstances or events that have the capacity to cause error. Category B - An error occurred but the error did not reach the patient. Category C - An error occurred that reached the patient but did not cause patient harm. Category D – An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and / or required intervention to preclude harm.

10. Medication Error Severity Classification based on the outcome to patient Category E - An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention. Category F - An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged length of hospitalization. Category G - An error occurred that may have contributed to or resulted in permanent patient harm.

11. Medication Error Severity Classification based on the outcome to patient Category H - An error occurred that required intervention necessary to sustain life. Category I - An error occurred that may have contributed to or resulted in patient death.

12. CONTRIBUTING FACTORS INCLUDE : Clinical information missing age, weight, allergy, diagnosis Miscommunication of drug order Illegible, ambiguous, incomplete, misheard, misunderstood order Drug Name, Label, Package P roblem Look / sound – alike name, look – a like packaging, unclear / no label Drug Storage Slow turnaround time, doses missing or expired, placed in the wrong bin

13. CONTRIBUTING FACTORS INCLUDE : Transcription inaccurate / omitted. Environmental Problem Lighting, noise Workflow Problem Workload increase Staffing Problem Staffing deficiencies, Lack of staff education Unavailable patient information prior to dispensing or administering a drug Lab values, allergies

14. CONTRIBUTING FACTORS INCLUDE : Ambiguous or incomplete medication order Use of prohibited abbreviations, poor handwriting Patient Education Problem Lack of information, non compliance, not encouraged to ask questions Procedure / Protocol not followed Wrong Computer Entry

15. 15 Can you read this??? Neither can we!!!

16. 16 Always use leading zeros for decimal points. The order should have read: Digoxin 0.5 mg

17. Approaches for reducing prescribing errors Electronic prescribing may help to reduce the risk of prescribing errors resulting from illegible handwriting Computerized physician order entry systems eliminate the need for transcription of orders by nursing staff    

18. Approaches to reducing dispensing errors include • Separating drugs with a similar name or appearance. • Awareness of high risk drugs. • Checking the patient’s identity. • Ensuring that dosage calculations are checked independently by another health care professional before the drug is administered. • Ensuring that the prescription, drug, and patient are in the same place in order that they may be checked against one another. • Ensuring the medication is given at the correct time.

19. STEPS TO BE TAKEN IN PREVENTING MEDICATION ERROR Follow the rights of medication administration Right patient Right drug Right dose Right time and frequency Right route Right documentation Right history and assessment Drug approach and Right to Refuse Right Drug-Drug Interaction and evaluation Right Education and Information

20. Be sure to read labels at least 3 times, before during after administration of the drug. Prepare the medicine in a well lighted room. Check the expiry date of the drug before administration. Be aware about ambiguous orders or drug names and numerical and Consult doctor if any doubt. Be alert to usually large dosage or excessive increase in dosage ordered. When in doubt, check order with prescriber. .

21. Double check all calculation, even simple calculation Routinely refer to drug interaction charts or drug reference source and commit common interactive drugs to memory. Do not use any unacceptable abbreviation and symbols, question if any one use Read the leaflet of the drug carefully when giving new drug first time. Do not make assumptions of illegible orders. Do not accept incomplete orders and telephone or verbal orders.

22. Double check with a client who has allergies about all new drugs as they are added in treatment plan Question a drug form used in unfamiliar way. Document all medication as soon as they are given. When you have made an error reflect on what went wrong ,ask how you could have prevented the error Evaluate the context for any medication error to determine if nurses have the necessary resources for safe medication administration. When repeated medication error occurs within a work area, identify and analyze the factors that may have caused the errors and take corrective action. Attend in-service program that focus on the drug you commonly administer.  

23. SUMMARY Stay alert! Question ! Learn!