medication administration ... medication administration errors jenna winters ferris state university

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  • MEDICATION ADMINISTRATION ERRORS

    Jenna Winters

    Ferris State University

    Nursing 450 Capstone

    “Despite our best efforts, medication errors happen every day, to

    every kind of person, in every health care setting”

    Michael R. Cohen, Institute for Safe Medication Practices (ISMP)

  • • Medication errors harm how many people each year? • 1.5 million

    • Institute of Medicine repots how many deaths due to medication errors in hospitals? • 7,000

    • Clinical nurses spend what percent of their time passing medications? • About 40%

    • Medication errors remain one of the most common patient safety-related adverse events in the acute care hospital

    • What route of administration has a higher risk for error than any other route?

    • Intravenous

  • • Identify types causes of medication errors

    • Relate theories to medication errors

    • Assess the healthcare environment

    • Root cause analysis

    • QSEN and ANA standards

    • Recommendations for quality and safety improvements

  • INTRODUCTION

    • 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP))

    • Administration of medications requires a combination of task focus and clinical reasoning skills

  • INSTITUTE FOR SAFE MEDICATION PRACTICES (ISMP)

    HIGH ALERT MEDICATIONS IN ACUTE CARE SETTINGS

    • High-alert medications: bear a heightened risk of causing pptient harm is used in error. Mistakes may not be more common, but the consequences of errors area more devastating

  • PEDIATRICS

    • Medication errors are more

    common in Pediatric vs Adult

    populations… Why?

    • Meds are formulated &

    packaged for adults

    • Weight based calculations

    required

    • Facilities are built around needs

    of adult patients, not children

    • Kids are less tolerable to errors

    • Emergency departments are

    particularly high risk settings

  • Josie King

  • Michael Blankenship

  • Thomas and

    Zoe

  • Emily Jerry

  • Kaia M. Zautner

  • Traniya Sampson

  • •Jasmine Gant

  • Josh Barron

  • BETTY NEUMANS HEALTH CARE SYSTEMS MODEL

    • Individuals interaction with internal and external environmental comprise the whole client system

    • Open system

    • Stability

    • Stressors

    • Resulting in either a positive or negative outcome

    • Prevention: keep stressors and the stress response from having a detrimental effect

    • Primary

    • Secondary

    • Tertiary

  • KARL WEICK’S ORGANIZATIONAL INFORMATION THEORY

    • Communication is crucial for organization survival

    • Collaboration

    • Individuals are guided by rules

    • Resolve uncertain situations by establishing reliable and accurate information and advocating appropriate responses

  • HEALTH CARE ENVIRONMENT

  • ROOT CAUSE ANALYSIS

    https://www.youtube.com/watch?v=uQ-Vns6X-Fc

    https://www.youtube.com/watch?v=uQ-Vns6X-Fc

  • INFERENCES AND IMPLICATIONS/CONSEQUENCES

    • Reporting

    • “We cannot fix what we do not know is wrong” (Unknown Author)

    • Why would a nurse NOT report an error?

    • Effects of errors

    • https://www.youtube.com/watch?v=tn3JTTnyuEY

    • Blame

    • Near misses should be reported too

    • Interdisciplinary collaboration

    https://www.youtube.com/watch?v=tn3JTTnyuEY

  • THE SECOND VICTIM

    • Kimberly Hiatt nurse caring for Kaia Zautner

    • Eric Cropp pharmacist responsible for Emily Jerry’s death

    • Julie Thao nurse responsible for death of Jasmine Grant http://www.youtube.com/watch?v =MtSbgUuXdaw

    • Suffering of the 2nd victim

    Fatal errors and those that cause harm are known to haunt healthcare practitioners

    throughout their life

    http://www.youtube.com/watch?v=MtSbgUuXdaw

  • ANA

    • Education

    • Communication

    • Environmental Health

    QSEN

    • Teamwork and collaboration

    • Safety

    • Quality Improvement • https://www.ismp.org/orderforms/reporterrortoismp.asp • https://www.accessdata.fda.gov/scripts/medwatch/

    https://www.ismp.org/orderforms/reporterrortoismp.asp https://www.accessdata.fda.gov/scripts/medwatch/

  • RECOMMENDATIONS

    • Use those critical thinking skills & analyze each medication

    • 3 Goals for Patient Safety

    • Eliminate error

    • Identify error before it reaches the patient

    • Alleviate harm if error does occur

    • Blame-free Environment for Reporting

    • Written Procedures

    • Med Pass “Time Out”

    www.youtube.com/watch?v=CmXsSfbBZu8

    http://www.youtube.com/watch?v=CmXsSfbBZu8

  • REFERENCES

    • American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Association.

    • Batalden, P., Bednash, G., Blackwell, J., Cronenwett, L., Day. L., Drenkard, K., … Tagliareni, M. E. (2014). Competencies. QSEN Institute. Retrieved from http://qsen.org/competencies/

    • Cook, P. (2014) Avoiding medication errors. Nursing New Zealand. 20(6). Retrieved from GALE.

    • Gonzales, K. (2010). Medication administration errors and the pediatric population: A systematic search of the literature, Journal of Pediatric Nursing, 25(6). doi http://dx.doi.org/10.1016/j.pedn.2010.04.002

    • Institue for Safe Medication Practices [ISMP]. (2014). A nonprofit organization educating the healthcare community and consumers about safe medication practices. Retrieved from http://www.ismp.org/default.asp

    • Institue for Safe Medication Practices [ISMP]. (2009). Plain D5W or hypotonic saline solution post-op could result in hyponatremia and death in healthy children. ISMP Medication Safety Alert, 14(16) Retrieved from http://www.nccmerp.org/errors-lead-fatal-hyponatremia-two-healthy-children

    • National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP]. 2014. About medication errors. Retrieved from http://www.nccmerp.org/aboutMedErrors.html

    • Nursing Theory. (2014).l Systems theory. Retrieved from http://www.nursing-theory.org/theories-and-models/neuman-systems-model.php

    • Quality and Safety Education for Nurses [QSEN]. (2014). QSEN Institute. Retrieved from http://qsen.org/competencies/

    • Sandlin, D. (2008). Pediatric medication error prevention. Journal of PeriAnesthesia Nursing. 23(4). doi 10.1016/j.jopan.2008.05.007

    • SEA Medical Systems. (2013). SEA medical systems. Retrieved from http://www.seamedical.com/?pg=home

    • The Joint Commission. (2008). Preventing pediatric medication errors. Sentinel Event Alter, 39. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_39.pdf

    • Tzeng, H., Yin, C., & Schneider, T. E. (2013) Medication error-related issues in nursing practice. MedSurg Nursing. 22(1). Retrieved from GALE.

    • Wittich, C. M., Burkle, C. M., & Lanier, W. L. (2014). Medication errors: an overview for clinicians. Mayo Clinical Proceedings. 89(8). Retrieved from GALE.

    http://qsen.org/competencies/ http://dx.doi.org/10.1016/j.pedn.2010.04.002 http://www.ismp.org/default.asp http://www.nccmerp.org/errors-lead-fatal-hyponatremia-two-healthy-children http://www.nccmerp.org/aboutMedErrors.html http://www.nursing-theory.org/theories-and-models/neuman-systems-model.php http://www.seamedical.com/?pg=home http://www.jointcommission.org/assets/1/18/SEA_39.pdf

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