copyright © 2008 thomson delmar learning the practical nurses role in preventing medication errors...

Copyright © 2008 Thomson Delmar Learning

The Practical Nurses Role in Preventing

Medication Errors8th EditionTextbook Chapter 9

Rev KBurger 0608


Medication Errors

• 10 percent to18 percent of hospital injuries attributed to medication errors

• 44,000 to 98,000 people die in U.S. hospitals annually due to medication errors


Medication Errors

• Effects of medication errors– Increase length of stay– Increased cost– Patient disability– Death– Nurse’s personal and professional status,

confidence, and practice


Nursing ResponsibilitiesLegal and Ethical

• Nurses are liable for their actions, omissions, and for those duties they may delegate to others.

• They are personally responsible…legally, morally and ethically…for every drug they administer.


Nursing Responsibilities• Obtaining current knowledge base of drugs • Referring to authoritative sources in professional

literature (less than 5yrs old)• Questioning a drug order that is unclear or that

appears to contain an error• Refusing to administer a drug if there is a reason to

believe it will be harmful.• Performing correct techniques and precautions• Monitoring client response and documenting drug

effects• Patient and family education


Nursing Responsibilitiescontinued

• Know Information about the medicationAction – side effects – appropriate doseAge specific considerations – routes

• Know Information about the clientWhat other medications are they takingALLERGIES or other problems w/ medsGag reflex – Impaired swallowingDietary and/or Fluid restrictionsCultural and/or religious influencesGenetic factorsVital signsLab values – renal & liver function / protein & albuminAge Pregnant/breast feeding


Nursing Responsibilitiescontinued

• Using correct techniques of preparation and administration to deliver medications safely.

• Monitoring the client for therapeutic and non-therapeutic effects of the drug

• Client education for safe and accurate self-administration of the drug.


Legal Controls in Pharmacology

Purpose and Scope of Legal Controls:

• Protect public health and safety

• Laws govern testing, production, distribution, prescription and the administration of drugs.


Federal Medication Laws1906 Pure Food & Drug Act Disclosure of dangerous ingredients

1912 Sherley Amendment No fraudulent claims of action

1914 Harrison Narcotic Act Established regulations for narcotics

1938 Food,Drug,CosmeticAct Drugs must be tested and proved safe

1952 DurhamHumphrey Amendment Established list of drugs needing RX

1962 Kefauver-Harris Amendment Drugs must be proven effective

1970 Controlled Substances Act Strict controls on distribution ***

1978 Drug Regulation Reform Act Shortened drug investigation time


***Controlled Substance Act • Designed to promote treatment and prevention of drug

dependence• Established controls such as:

-Prescribers are registered with the DEA. A registry number is issued to each person and is renewed annually.-Complete written records of all drugs prescribed must be kept for two years. Pharmacists record each sale in triplicate. Schedule II drug prescriptions cannot be renewed.-DEA (Drug Enforcement Agency) monitoring

• Health care agencies must establish policies to comply with Federal law.


-All units have a record of every controlled drug on the unit and two nurses at the change of every shift count all drugs.-All controlled drugs are stored using a double lock system. Keys to medication areas are under the control of nurses on the unit. -Discarding of controlled substances must be witnessed by another nurse-Written renewal orders are required every 72 hours for narcotics and schedule II & III drugs.

Controlled Substance Act - continued


Control Schedule

Drugs with a significant potential for abuse

are classified into 5 categories or schedules:

Schedule I: highest potential for abuse Illicit drugs (Heroin, LSD, Marijuana)

Schedule II: (Morphine, Dilaudid)

Schedule III: (Vicodin, Meperidine)

Schedule IV: (Valium, Xanax)

Schedule V: lowest potential for abuse (OTC cough suppressant

w/codeine)


Drug Information Resources • Agency pharmacists are an appropriate resource

for obtaining drug information on the job.• Nursing drug handbooks: contain drug information

along with nursing considerations.• Physician's Desk Reference (PDR) Contains

manufacturer's descriptions (package inserts) which are written using FDA standards, but may be slanted in favor of the drug being described.

• Package Inserts: Required by law for insertion with each new drug and must include a description, indications, precautions, dosage, and contraindications.

• Electronic databases and Internet


Adverse Drug Events (ADE)• An undesirable occurrence related to

administration of or failure to administer a prescribed medication.

• General term that includes all types of clinical problems encountered regarding medications including:- adverse drug reactions (ADRs)

adverse effects allergic reaction

idiosyncratic reaction-medication errors (MEs)


Adverse Drug Reaction ADR

• Any unexpected, undesired or excessive response to a medication given in therapeutic dosages) that results in:- temporary or serious harm or disability- admission to hospital, higher level care or prolonged stay- death


Adverse Drug Reaction continued

• Adverse Effects:-Expected side effects (ie stomach upset)-Dose-related reactions (ie liver or renal impairement, geriatric and/or pediatric considerations)-Drug/Drug or Drug/Food interactions (ie potentiation of drugs by another drug, or drug not absorbed well with food)


Adverse Drug Reaction continued

• Allergic Reaction:-Hypersensitivity ( ie: rash, anaphylaxis)

• Idiosyncratic Reaction:-abnormal and unpredicted response specific to an individual (ie: confusion and antibiotics)


Nursing Measures to Prevent Medication Errors

Order interpretation, reconciliation, and confirmation

• Never assume anything about a drug order. CLARIFY, CLARIFY, CLARIFY

• Make sure medication orders contain all (7) parts• Minimize use of verbal or telephone orders. If

used, spell all drug names and repeat to confirm ( NOT LPN Scope)

• Check Medication Administration Records (MAR)to the original prescriber order as per agency protocol.


Nursing Measures to Prevent Medication Errors

Safe Medication Administration

• USE THE SIX RIGHTS– Right drug– Right route– Right patient– Right dose– Right time– Right documentation


Right Patient• Correctly identify patient prior to

medication administration using at least (2) identifiers.– Compare medical record number (MRN) on client

armband with medication administration record (MAR)

– Ask the patient to state his name & DOB– Compare picture to patient if available– Technological advances to prevent errors

Bar-coding


Right Patient

• Tell patient at time of administration what medication and dosage is being administered. Briefly explain therapeutic use of each medication– Patient may question drug or dosage– Re-confirm the drug order in chart and MAR– Provides an opportunity to do medication teaching


Right DrugThe (3) Checks

• Check medication label 3X– On first contact with drug; when removing from

medication box– Prior to measuring

• Pouring, counting, or withdrawing

– Just prior to administration; when returning to medication box


Right Drug• Be aware of distractions• Do not multitask during drug administration • Use bar-coding scanning when available• Be knowledgeable about the drug’s actions,

indications, and contraindications• Be extremely vigilant about known

HIGH ALERT MEDICATIONS• Be alert to Look-a-like , Sound-a-like medications• Do not accept Drug Name Abbreviations

(IE MS for Morphine Sulfate )


HIGH ALERT MEDICATIONSSound-a-like Look-a-like DRUGS• ISMP List of High-Alert

Medications HYPERLINK

• Top (5) drugs involved in harmful errorsPINCH

PotassiumInsulinNarcotics CoumadinHeparin

• ISMP List of Confused Drug Names HYPERLINK

• Example:Tegretol versus Toradol(anticonvulsant versus antiinflammatory)Paxil versus Plavix(antidepressive versus antiplatelet)

• Use TALL-MAN letters• Know both generic and

trade names of drugs


Right Route

• Consult a drug information source to confirm correct route

• Do not accept incorrect abbreviations:sq or sc – WHAT IS PREFERRED?JCAHO Do not Use List

• Example: Be careful of:IVP versus IVPB


Right Route

• May need to change or clarify forms or routes of the drug for safe medication administration– NPO status– Client inability to swallow pills– Nasogastric or surgically inserted tubes– Time-released or enteric-coated medications


Right Time

• Order should include frequency of administration

• Administer medications within 1 hr of prescribed time ( or per facility guidelines)

• Use safe abbreviationsDo not accept: QD or QODWHAT IS PREFERRED???


Right Dose

• Carefully read and clarify drug orders

• Do not accept illegible handwriting

• Do not accept leading or trailing zeroes

• Do not accept U or IUWHAT IS PREFERRED?

• Recheck labels 3 times!


Right Dose

• Have two nurses double-check high alert medications

• Consult drug references

• Consider developmental age of client

• Accurate dosage calculations


Right Documentation

• Document IMMEDIATELY after administrationNEVER DOCUMENT BEFORE!!!

• Omitting documentation can result in over or undermedication


Ethical Considerations

• Respect of patient rights

• Vigilant patient advocacy

• Maintenance of knowledge and skills

• Dedication to improvements in practice

• Notification of patients regarding errors

• Whistle-blowing


Genetic Factors• Age-related Factors:

Pediatric- -absorption, distribution, metabolism, excretion differences- weight based dosing

Geriatric- decreased body fat, lean muscle, water- decreased plasma proteins- diminished GI motility and absorption- slower liver and kidney function

• Inherited Factors:– Slow versus Fast Acetylators

differences in metabolism of drugs(IE: Asian Americans need lower doses of the antiaxiety drug Haldol)

– Known Genetic group differences(IE: African Americans respond better to CCB drugs for hypertension)


Cultural Considerations

• Varying health beliefs and practices

• Folk and/or home remedies

• Religious practices

• Dietary practices

• RESPECT for client’s cultural context

copyright © 2008 thomson delmar learning the practical nurses role in preventing medication errors...

Documents

drug order

drug client education

practice slide

medication action

prevention of drug dependence

family education slide

administration of drugs

federal medication laws