Medication Safety & The Nurse

Kechi Iheduru

Fall 2013

Objectives

• Describe and explain various categories of rights

• Explain how these rights work together to promote patient safety in the context of organizational system.

• Discuss the many factors that contribute to medication errors.

• Describe the factors that increase safety risks with medication administration.

• Discuss interventions that promote safety with medication administration.

• Using a medication error case, identify which rights were not upheld and analyze how organizational systems affected the actions of the nurse

Medication Error

• Definition: 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 (Hughes& Blegen,2008).

• This presentation is devoted entirely to medication error prevention and safe medication use.

• Providing accurate medication safety information

http://www.justice.org/images/newsroom/CauseofDeath.jpg

Definitions

• Side-effect:

• A known effect, other than that primarily intended, relating to the pharmacological properties of the medication. For example, a common side effect of opiate analgesia is nausea.

• Adverse reaction

• Unexpected harm arising from a justified action where the correct process was followed for the context in which the process occurred. For example, an unexpected allergic reaction in a patient taking a medication for the first time.

• Error

• Failure to carry out a planned action as intended or application of an incorrect plan.

• Adverse event

• An incident that results in harm to a patient. Adverse drug event

• An incident that may be preventable (usually the result of an error) or not preventable (IOM, 2006).

• Medication error

• May result in:

• an adverse event if a patient is harmed;

• a near miss if a patient is nearly harmed;

• neither harm nor potential for harm.

High-Alert Medications

• High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error.

• Although mistakes may or may not be more common with these drugs, the consequences of an error are clearly more devastating to patients.

• These medications require special safeguards at practice site to reduce the risk of errors. (Institute for Safe Medication Practices, 2014).

National Patient Safety Goals 2013

• Goal 1

• Improve the accuracy of patient identification.

• Use at least two patient identifiers when providing care, treatment, and services.

• Goal 2

• Improve the effectiveness of communication among caregivers.

• Goal 3

• Improve the safety of using medications.

• Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

• The Joint Commission (JC), (2013)

Complexity of Medication

• Many different routes of delivery, variable actions (long acting, short acting), drugs with the same action and formulation but with different trade names.

• Multiple medications and there are more patients with multiple co-morbidities. Increases the likelihood of drug interactions, side-effects and mistakes in administration

• Process of delivering medications to patients is often shared by a number of health-care professionals.

Complexity of Medication Cont.

• Physicians, NPs and PAs are prescribing a larger range of medications so there are more medicines they need to be familiar with.

• Providers take care of r patients taking medications prescribed by others (often specialist) and hence may not be familiar with the effects of all the medications a patient is taking.

The scale of medicationerror

• Medication error is a common cause of preventable patient harm.

• The Institute of Medicine estimates:

• 1 medication error per hospitalized patient per day in the United States; (IOM, 2006)

• 1.5 million preventable adverse drug event per year in the United States; (IOM, 2006)

• 7000 deaths per year from medication error in US hospitals (WHO, 2007).

Error-Prone Processes

• There are five stages of the medication process:

• (a) ordering/prescribing,

• (b) transcribing and verifying,

• (c) dispensing and delivering,

• (d) administering, and

• (e) monitoring and reporting(Hughes& Blegen,2008).

Transcribing, Dispensing, and Delivering

• Medication ordered by physician are transcribed by the nurses,

• transcribing and verifying

• Dispensed by the pharmacy, and

• Then delivered to the unit for nurse administration

• Failure to transcribe the order or incorrect transcription,

• incorrectly filling the order, and

• failure to deliver the correct medication for the correct patient.

• Process of delivering medications to patients is often shared by a number of health-care professionals.

• Communication failures can lead to gaps in the continuity of the process.

Consequences of Using Error-Prone Abbreviations

• Misinterpretation may lead to mistakes that result in patient harm

• Delay start of therapy due to time spent for clarification

“Do Not Use” List

• The Institute for Safe Medication Practices (ISMP) and the Food and Drug Administration recommend that ISMP’s list of error-prone abbreviations be considered whenever medical information is communicated.

• Complete list is located at:

• www.ismp.org/Tools/errorproneabbreviations.pdf

Medication administration

• Nurses are primarily involved in the administration of medications across settings

• Classic administration errors are a drug being given to the wrong patient, by the wrong route, at the wrong time, in the wrong dose or the wrong drug used. wrong time, wrong rate, or wrong dose

• Not giving a prescribed drug is another form of administration error

• These errors can result from inadequate communication, slips or lapses, lack of checking procedures, lack of vigilance, calculation errors, knowledge or performance deficits and suboptimal workplace and medication packaging design.

• Inadequate documentation.

• There is often a combination of contributory factors.

Monitoring

• Types of errors in monitoring:

• inadequate monitoring for side-effects;

• medication not ceased once course is complete or clearly not

helping the patient;

• course of prescribed medication not completed;

• drug levels not measured, or measured but not checked or acted

upon;

• communication failures—this is a risk if the care provider

changes, for example, if the patient moves from the hospital

setting to the community setting or vice versa.

Contributory Factors forMedication Errors

• Adverse medication events are frequently multifactorial in nature.

• Patient factors:

• patient on multiple medications;

• patients with a number of medical problems;

• patients who cannot communicate well, e.g. unconscious, babies and young children, people who do not speak the same language as the staff;

• patients who have more than one doctor prescribing medication;

• patients who do not take an active interest in being informed about their own health and medicines;

• children and babies (drug dose calculations required).

• Staff factors:

• inexperience;

• rushing, emergency situations;

• multitasking;

• being interrupted mid-task;

• fatigue, boredom, lack of vigilance;

• lack of checking and double-checking habits;

• poor teamwork, poor communication between colleagues;

• reluctance to use memory aids.

• Workplace design factors:

• absence of safety culture in the workplace. This may be evidenced

by a lack of reporting systems and failure to learn from past near

misses and adverse events;

• absence of readily available memory aids for staff;

• inadequate staff numbers;

• medicines not stored in an easy to use form.

• Medication design factors:

• Look-a-like, sound-a-like medication.

• For example, Celebrex (an anti-inflammatory), Cerebryx (an

anticonvulsant) and Celexa (an antidepressant);

• Ambiguous labeling—different preparations or dosages of similar

medication may have similar names or packaging.

• For example, some slow release medications may differentiate

themselves from the usual release form with a suffix. Unfortunately,

there are many different suffixes in use to imply similar properties

such as slow release, delayed release or long acting, e.g. LA, XL, XR,

CC, CD, ER, SA, CR, XT,SR.

Impact of Working Conditions on Medication Errors

• Medication safety for patients is dependent upon systems, process, and human factors, which can vary significantly across health care settings.

• Systems factors:

• Nurse staffing; staffing levels and RN skill mix

• shift length,

• Workloads

• patient acuity, and

• organizational climate: organizational climate/favorable working conditions, policies and procedures, and technologies enabling safety or contributing to MAEs

• Process factors: Process factors that influence medication administration include hidden failures that can initiate events resulting in errors. Such as;

• Administrative processes.

• Technological processes: Equipment failure while administering

medication.

• Clinical processes: Documentation of the medication administration

process.

• Factors such as interruptions and distractions.

• Individual vs. teamwork,

• Physical/cognitive requirements,

• Treatment complexity,

• Workflow.

• Human Factors on Medication Administration Errors

• Effects of fatigue and sleep loss

• Lack of medication knowledge is a constant problem.

• Experience and skills also impact thought processes.

• Thought process can also be altered by distractions and

interruptions

• Knowledge or performance deficits

• Miscommunication

Environmental conditions

• The essential environmental conditions conducive to safe medication practices include;

• (a) the right to complete and clearly written orders that clearly specify the drug, dose, route, and frequency;

• (b) the right to have the correct drug route and dose dispensed from pharmacies;

• (c) the right to have access to drug information;

• (d) the right to have policies on safe medication administration;

• (e) the right to administer medications safely and to identify problems in the system; and

• (f) the right to stop, think, and be vigilant when administering medications

System Safeguard

• Understand the core elements that significantly influence

the safe use medication.

• Knowledge and understanding of the common causes of

medication errors.

• Establish security processes to ensure adequate control

of medications outside of the pharmacy.

• Document the destruction of medication waste at the

time of removal of the medication whenever possible.

• Require two signatures for narcotic waste as appropriate.

• Proactively monitor drug usage patterns, waste reconciliation,

and discrepancies.

• Immediately address any discrepancies with medication counts

and waste at the time of discovery.

• Conduct random medical record audits

• Provide sufficient patient and drug information on the medication

sheets.

• Patient:

• Complete patient’s name

• Patient allergies.

• Patient location.

• Medication

• Generic and brand names (name of medication on the medication

label should match the medication administration record (MAR)

and physician’s order.

• Provide administration instructions

• Provide special instructions (do not crush)

• Provide selective warnings (high-alert medication; double-check)

• Flag orders such as (dose changed, discontinued etc.)

• Updating MAR (Demonstration using the MAR)

• Reordering medications from pharmacy (Demonstration using

pharmacy reordering forms and receipt book).

• Documenting missing med doses.

Nursing Responsibilities• Only administer meds you have prepared.

• Know the purpose and expected outcomes.

• Do not leave meds at bedside.

• Check identification bracelet (Patient’s name) before administering medicines.

• Some meds need verification/checking by another nurse.

• Intramuscular(IM) injections - no more than 3ml at one site.

• Consult with supervisor or MD if dosage is outside of recommended dosage range.

• Do not administer medications calculated by someone else except pharmacist.

• Exercise extra caution with pediatric patients.

• IV pump does not replace the responsibility of the nurse

Six Rights Of Medication Administration

• When you are giving medication, regardless of the type of

medication, you must always follow the six rights.

• 1. Right individual

• 2. Right medication

• 3. Right dose

• 4. Right time

• 5. Right route

• 6. Right documentation

• Each time you give a medication, you also need to remember to do the "Three Checks". This means that you are going to do a "triple-check" to make sure that the six rights are present each time that you give a medication. You must:

• 1. Remove the medication from the locked area and check the prescription label against the medication log to make sure that they match: this is the 1st check.

• 2. Before pouring the medication, check the prescription label against the medication order to make sure that they match: this is the 2nd check.

• 3. After you pour the medication, but before you give it, check the prescription label against the medication log entry again to make sure that they match: this is the 3rd check.

Parts of Safe Medication Administration

Six rights

Nurses’ rights

Patients’ rights

Principles of Medication Administration

• Talk with the individual and explain what you are doing before you give medications. Answer any questions that the individual have.

• Help the individual to be as involved as possible in the process.

• Provide privacy for the individual.

• Give medication administration your complete attention.

• Give medications in a quiet area, free from distractions.

• Never leave medications unattended, even for a moment!

• Wash your hands! You must wash your hands before and after administering medications.

Standard Precautions

• Wear gloves for parenteral injections

• Wash hands before beginning medication pass

• Keep medication cart clean

• If you do more than hand the pills to a patient, wash hands before leaving the room

• Wear gloves if helping put pills in mouth

Right Individual

• 1. Prepare medication for one individual at a time.

• 2. Give the medication to the individual as soon as you prepare it.

• 3. Do not talk to others and ask them not to talk to you during medication administration.

• 4. Do not stop to do something else in the middle of giving medications.

• 5. Pay close attention at all times when you are administering medications.

• You must also compare the individual's name on the prescription label, the medication order and the medication log. Make sure that they match.

• If they do not match, or if there is any doubt about whether you are giving the medication to the right individual, STOP! ASK QUESTIONS!

• If you make a mistake, follow your agency's policy for reporting medication errors.

Right Medication

• In order to be sure that you are giving the right medication, you must:

• Read the medication label carefully (remember that some medications have more than one name: a brand name and at least one generic name).

• Check the spelling of the medication carefully. If there is any doubt about whether the medication name is correct, stop and double check with another nurse or the pharmacist before you give the medication.

• You may also call the ordering physician.

• Read the medication order carefully. Make sure that the medication name on the order matches the medication name on the label.

• Read the medication log carefully. Make sure that the medication name on the label, the medication order and medication log match before giving the medication.

• Look at the medication. If there is anything different about the size, shape or color of the medication, call the pharmacist before you give it.

• It could be that you have been given a different generic brand of the medication. But sometimes when a medication looks different it means that you have the wrong medication.

• Compare the medication name on the prescription label, the medication order and the medication log.

• If they do not match, or if there is any doubt that you are giving the right medication, ! ASK QUESTIONS!

• If you make a mistake, follow your agency's policy or procedure for reporting medication errors.

Right Dose

• The right dose is how much of the medication you are supposed to give the individual at one time.

• To determine the dose, you need to know the strength of each medication.

•• In the case of liquid medications, you need to know the

strength of the medication in each liquid measure.

• The dose equals the strength of the medication multiplied by the amount.

• Look at the sample label below.

Sample Medication Label

RX #:828291 Town Pharmacy

100 Main Street

Pineville, MA 00000

(617) 000-0000

• Jeff Smith 09/29/00

• Valproic Acid 250mg

• (I.C. Depakote)

• Take 2 tabs by mouth twice a day

• By Dr. B.J. Honeycutt

• Lot #: PS 56721 Exp. Date: 9/29/01 Refills: 4

• Compare the dose on the prescription label, the medication order and the medication log.

• If they do not match, or if there is any doubt that you are giving the right dose, STOP! ASK QUESTIONS!

Right Time

• Some medications must be administered only at very specific times of the day. For other medications, the time of day that you give the medication is less critical.

• For example, some medications must be given before meals, one hour after meals or at bedtime in order to work best.

• It is very important for medication to be given at the time of day that is written on the medication order.

• If no specific time is written on the medication order, ask the nurse or pharmacist about the best time of day to give the medication.

• Write this down on the medication log.

• Compare the time on the prescription label, the medication order and the medication log.

• If they do not match, or if there is any doubt about whether you are giving the medication at the right time, ASK QUESTIONS!

• Medications must be given within a ½ hour of the time that is listed on the medication log.

•• This means that you have ½ hour before the medication is

due, and ½ hour after it is due to administer the medication in order to be on time with medication administration.

• The ½ hour timeframe does not apply to PRN medications.

• For example: If you have a PRN medication order and PRN protocol for Tylenol to be given every 4 hours as needed, you cannot give it until 4 hours have passed since the last dose.

• What if a prescribing practitioner writes a medication order for “am,” “pm,” or “hs?”

• Follow your company policy or individual client preference.

•• All nurses should be familiar with institutions internal

systems of reporting medication errors.

Right Route• The route means how and where the medication goes into the

body.

• Most medication is taken into the mouth and swallowed, but others enter the body through the skin, rectum, vagina, eyes, ears, nose, and lungs, through a g-tube or by injection.

• The most common way (or route) for medications to enter the body is by mouth.

• Compare the route on the prescription label, the medication order and the medication log.

Routes of Administration

• Oral

• By mouth

• By Gastric tube

• By Nasogastric tube

• Buccal

• Sublingual

• Topical - to treat skin or mucous membrane (oral, nasal, ear, eye, vaginal, rectal)

• Transdermal - for systemic dosage

• Parenteral

• Intradermal - testing

• Subcutaneous

• Intramuscular

• Intravenous medications, RN only

• Direct intravenous push

• Intermittent "piggy back"

• Continuous infusion

• If they do not match, or if there is any doubt about whether you are giving the medication by the right route, STOP! ASK QUESTIONS!

• Sometimes mistakes happen when you are giving several medications by different routes at the same scheduled time.

• For example, you may be giving an eye drop and an eardrop to the same individual at the same time. If you become distracted, you could accidentally put the eardrops in the individual’s eye. This would be a very serious mistake.

• Avoid this type of mistake by giving the eye drops first, and then put away the eye drops. After you have put the eye drops away, give the ear drops.

Right Documentation

• Inadequate documentation.

• Your responsibilities are not yet complete!

• Each time a medication is administered, it must be documented.

• Your documentation of medication administration must be done at the time that you give the medication.

• You must complete all of the documentation that is required on the medication log.

• For example, if a medication is administered but has not been recorded as being given, another staff member may also give the patient the medication thinking that it had not yet been administered.

• Documentation should be done in black ink pen.

• No pencil or white out can be used.

• Never cross out or write over documentation.

• If you make a mistake when you are documenting on the medication log, circle your mistake and write a note on the back of the MAR and the log to explain what happened.

• Double check your documentation as soon as you have finished giving medications and again at the end of the day.

• If there is someone else that can double-check your documentation for you, ask him or her to go over your medication log documentation to make sure that it is complete.

• All documentation must be done at the time that the medication is administered.

• If there is any question about documentation on the medication log, STOP! ASK QUESTIONS!

Documentation

• Avoid the use of ambiguous, vague, unclear and confusing abbreviations in written orders, medication administration records, storage bins/shelf labels, and preprinted protocols, and you notes.

• See resource section for ISMP’s list of error-prone abbreviations.

Intended dose of 4 units in patient history interpreted as 44 units. “U” should be written out as “unit.”

Example 1

Intended dose of “.4 mg” interpreted as 4 mg from medication order. Should be written as “0.4 mg.”

Example 2

“Potassium chloride QD” in medication order interpreted as QID. Should be written as “daily.”

Example 3

Intended recommendation of “less than 10” was interpreted as 4. “<” should be written out as “less than.”

Nurses’ rights regarding safe medication administration

• What do nurses have the right to expect in the workplace to arm themselves with the knowledge, skills, tools, and environment necessary to achieve the five rights of medication use?

• Right to a complete and clear order

• Right to have the correct drug, route (form), and dose dispensed

• Right to have access to information

• Right to have policies to guide safe medication administration

• Right to administer medications safely and to identify system problems

• Right to stop, think, and be vigilant when administering medications• Institute for Safe Medication Practices, (2007).

Safe Practice Skills

• Report and learn from medication errors and near misses

• Documentation : Clear, legible, unambiguous documentation

• Teamwork and communication surrounding medication use.

• Medication administration: Check the 6 Rights whenever administering a medication.

• Involve and educate patients about their medications

• Learn and practice drug calculations.

• Perform a medication and allergy history.

• Monitoring patients for side-effects.

•Provide staff education and competency validation

Scenario I: Erroneous administration of drugs

• Description of event

• During the early hours of the morning shift, the morning shift nurse administered subcutaneous regular insulin 100 units, instead of 10 units as was written in the physician’s order. The error stemmed from the physician’s illegible handwriting.

• The patient suffered from dementia, was uncooperative and seemed to be asleep. During the nurse’s regular checkup, she discovered the patient to be completely unresponsive. A blood test confirmed that the patient was in a state of hypoglycemic shock. The on-call physician was called, and the error was discovered.

• The patient was treated with an infusion of glucose 50% IV. A crash cart was brought to the patient’s room to be on hand. The patient recovered within a few minutes, woke up and began behaving normally.

• Role playing actor

• Later on in the morning shift, the patient’s son, a lawyer, comes to visit his father. Looking agitated, he turns to the nurse asking, “What happened to my father?” His father’s room-mate told him there was a problem and there were many people at his father’s bedside at the beginning of the morning shift. The nurse responsible for the error and care of the patient is called to speak with the patient’s son.

• The nurse explains the chain of events, takes

responsibility for and admits her error, the patient’s son is

not satisfied and responds, “Is that the level of care my

father has been receiving?”, “What kind of nurses work in

this unit?”, “I won’t have it, I will take action!”, “I demand

to speak to the supervisor and physician immediately!”,

“I demand to see this event’s report!”. Needless to say, if

the nurse does not explain the error and its details, the

patient’s son is upset and unwilling to accept any kind of

explanation.

Case 2 with questions for discussion:An administration error.

• A 38-year-old woman comes to the hospital with 20

minutes of itchy red rash and facial swelling. She has a

history of serious allergic reactions. A nurse draws up 10

mls of 1:10,000 adrenaline (epinephrine) into a 10 ml

syringe and leaves it at the bedside ready to use (1 mg in

total) just in case the doctor requests it. Meanwhile, the

doctor inserts an IV cannula. The doctor sees the 10 ml

syringe of clear fluid that the nurse has drawn up and

assumes it is normal saline. There is no communication

between the doctor and the nurse at this time.

• The doctor gives all 10 mls of adrenaline (epinephrine)

through the IV cannula thinking he is using saline to flush the

line. The patient suddenly feels terrible, anxious, becomes

tachycardic and then becomes unconscious with no pulse.

She is discovered to be in ventricular tachycardia, is

resuscitated and fortunately makes a good recovery.

Recommended dose of adrenaline (epinephrine) in

anaphylaxis is 0.3–0.5 mg IM. This woman received 1 mg IV.

Resources• Institute for Safe Medication Practices (ISMPs) List of High-

alert medication: https://www.ismp.org/Tools/institutionalhighAlert.asp

• WHO Collaborating Centre for Patient Safety Solutions - Look-Alike, Sound-Alike Medication Names: http://www.jointcommission.org/LASA/.

• Institute for Safe Medication Practices - ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations: https://www.ismp.org/tools/errorproneabbreviations.pdf.

• 2014-15 Targeted Medication Safety Best Practices for Hospitals: https://www.ismp.org/Tools/BestPractices/Default.aspx

Resources

• For more information and tools to help promote safe practices, visit:

• www.ismp.org/tools/abbreviations

• or

• www.fda.gov/cder/drug/MedErrors

References• Hughes, R. G. & Blege,n M.A. (2008). Medication Administration Safety. In: Hughes RG, editor. Patient Safety and Quality:

An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 37. Available from: http://www.ncbi.nlm.nih.gov/books/NBK2656/

• Institute for Safe Medication Practices, (2007). ISMP Medication Safety Alert! Nurses’ rights regarding safe medication administration. Nurse Advise-ERR Nurse, 5(7). Retrieved September 23, 2013 from www.ismp.org/newsletters/nursing/Issues/NurseAdviseERR200707

• Institute of Medicine (2006). Institute of Medicine: Preventing medication errors. Report brief. Washington, DC: National Academy Press

• World Health Organization (WHO). (2007). The conceptual framework for the international classification for patient safety. Geneva, World Health Organization, World Alliance for Patient Safety.

• World Health Organization. (nd). Topic 11: Improving medication safety. Retrieved September 23, 2013 from http://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf.

• World Health Organization. (nd) .Topic 7: Introduction to quality improvement methods. Retrieved September 23, 2013 from http://www.who.int/patientsafety/education/curriculum/who_mc_topic-7.pdf.

• The Joint Commission (JC), (2013). National Patient Safety Goals Effective January 1, 2013. Retrieved September 23, 2013 from www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_HAP.pdf

• Abbreviation slide set (2014) Eliminating Error-prone Abbreviations, Symbols, and Dose Designations. Retrieved March 29, 2014 from http://www.ismp.org/tools/abbreviations/