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Quarterly Medication Error Data April 2006

Author: grant-lee-james

Post on 04-Jan-2016




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  • Quarterly Medication Error DataApril 2006

  • Quarterly Error Report - ReviewMedication Error data based upon Safety ReportsNo report = No dataGreater than 51% of RNs 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 Patients 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 for Serious Medication ErrorsLeape, JAMA 1995OEeMAR

  • Quarterly Error Report10/2005 12/2005Ordering: 20 (11%)Dispensing: 10 (5.5%)Administration: 144 (83%)Total: 174

  • Quarterly Error Report1/2006-3/2006Ordering: 7 (4.6%)Dispensing: 17 (11.4%)Administration: 125(84%)Total: 149

  • Quarterly Error Report10/2005 12/20051/2006 3/2006

  • Emerging ThemesSystem only as good as the user that drives it. Confirmation of Schedules.Alaris and PCA Pump Programming.Failure to read Instructions

  • Top Nine

  • Error Types 1/2006 3/2006

  • Reported Causes of Error

  • eMAR Error Prevention Data

  • Medication 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 MessageWhen medications do not scan properly, call pharmacy.

  • Medication ErrorNurse had 2 bags (lopressor and dilaudid) of medication for her 2 patients in her hand. Scanned dilaudid. Hung lopressor.

  • Medication ErrorsPatient 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 - SchedulingFentanyl 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.

  • Questions? Please email Carol [email protected]

    This error prevention data from all pods on the eMAR over three months from August October 2005. This started one month after the completion of our hospital wide rollout so some pods were on 6 months others just one month. They identify near misses . In each of these categories the nurse received a prompt in the system that told them they scanned: the wrong drug ,dose or route or the wrong patient orthey scanned a medication that had expired.These prompts are what we call a hard stop in the application. The user is forced to stop, check what they are scanning and start over.On average this means our nurses were receiving 1.6 alerts per patient during this period.