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 MEDICATIONSIN 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

MichaelBlankenship

Thomas and

Zoe

Emily Jerry

Kaia M. Zautner

TraniyaSampson

•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

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

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 Granthttp://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

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/

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

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). doihttp://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.