Quarterly Medication Error Data
April 2006
Quarterly Error Report - Review
Medication Error data based upon Safety ReportsNo report = No dataGreater than 51% of RN’s report they have made a medication error in the past 12 months.*Only 5% of significant errors are reported. *Reports are completed*
Error is life-threateningMedication Vital to Patient’s Treatment
*Lowe, Debra K and Belchre, Jan V. 2002. Reporting medication Errors Through Computerized Medication Administration. CIN: Computers, Informatics Nursing. 20:5. 178-183.
Error Stage Error Stage for Serious Medication for Serious Medication
ErrorsErrors
Ordering
39%
Administer
38%
Dispensing
11%Transcription
12%
Leape, JAMA 1995
OEOEeMAReMAR
Quarterly Error Report10/2005 – 12/2005
Ordering: 20 (11%)Dispensing: 10 (5.5%)Administration: 144 (83%)Total: 174
Ordering Dispensing Administration
Quarterly Error Report1/2006-3/2006
Ordering: 7 (4.6%)Dispensing: 17 (11.4%)Administration: 125(84%)Total: 149 Ordering Dispensing Administration
Quarterly Error Report
Ordering Dispensing Administration Ordering Dispensing Administration
10/2005 – 12/2005 1/2006 – 3/2006
Emerging Themes
System only as good as the user that drives it. Confirmation of Schedules.Alaris and PCA Pump Programming.Failure to read Instructions
Top Nine
51
2420 20
17
10 85 4
0
10
20
30
40
50
60
1st Qtr
Wrong Frequency
Pump Programming
Ordering
Wrong Dose
Wrong Med
Dispensing
Other
No allergy order
Communication
Error Types 1/2006 – 3/2006
0
510
1520
2530
3540
4550
2nd Qtr
Wrong DoseWrong FrequencyWrong MedNarcotic CountWrong Route
Reported Causes of Error
0
10
20
30
40
50
60
70
2nd Qtr
Human Error
Transcription
Dispensing
Pump Programming
Scheduling
Failure to read Instructions
Ordering
eMAR bugs
Unknown and Other
Communication
Ignoring Reconcile
No Allergy Order
eMAR Error Prevention Data
January 2006-March 2006Total Patients 13,177Total Administrations 1,198,76
3Wrong Drug Intercepted 18,489Wrong Patient Intercepted 484Expired Medications Intercepted
2079
Medication ErrorsMedication ErrorsOrder for Robitussin with codeine
Pharmacy dispensed Robitussin DM
Emar scan indicated “wrong med”
Nurse consulted other staff who told her “it never scans right”
Nurse gave the Robitussin DM as a manual administration and indicated “bar code unreadable” as reason for manual entry
Take Away Message
When medications do not scan properly, call pharmacy.
Medication Error
Nurse had 2 bags (lopressor and dilaudid) of medication for her 2 patients in her hand. Scanned dilaudid. Hung lopressor.
Medication Errors
Patient ordered for 250 mg of Erythromycin via G tube. Nurse administered 250 mL. Error discovered when nurse called pharmacy for more medication for next dose.
Medication ErrorTwo IV bags hanging at bedside – Heparin and NS. Hung antibiotic secondary bag and mistakenly infused the Heparin bag instead.
Medication Error - Scheduling
Medication Error - Scheduling
Fentanyl dose changed from 100 mcg to 300 mcg. Default dosing indicated first dose for the next day. Nurse did not change schedule. Patient waited until the next day for increased dose.
