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 LuppiCluppi@partners.org

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.