MINIMISING MEDICATION ERRORS

Medication Errors

Aims.– To discuss the number and types of

medication errors and the ways in which they may be minimised

– To demonstrate how analysis of reported incidents can identify systems errors.

– To raise awareness of reporting ‘near misses’

Medication Errors

Objectives.To increase understanding of the

– Systems errors which lead to medication errors.

– Potential risks associated with the administration of medications

– Basis for reviewing the drug administration process.

– Trust policy on drug administration.

Percentage of nurses time spent on medication related activities by grade

GFED

Percentage of nurses time spent on medication activities

prepcheckadminchart

NMC RULES

The NMC expects any nurse to administer medications in a technically safe manner and to make a clinical and professional contribution to the process.

Principles of safe care drug administration7 R’s

Right DrugRight PatientRight TimeRight RouteRight DateRight PrescriptionRight Dose

So you think you are a safe drug giver?

1. How often are you asked to check another persons drugs at the same time you are dispensing medication? (Sometimes: 2)(Never: 0)

2. How often do you try to do two things at once, i.e. answer the telephone and check drugs? (Sometimes: 2) (Never: 0)

3. If you are preparing a familiar drug how often do you guess at the dose if you could not read the doctors handwriting? (Sometimes: 2) (Never: 0)

4. How often do you ‘cut corners’ in implementing the drug administration policy? (Sometimes: 1) (Never: 0)

5. Have you ever made a drug error? (Y: 2) (N: 0)

So you think you are a safe drug giver?

6. How often have you given a drug to an in-patient who was not wearing a name band? (Sometimes: 1) (Never: 0)

7. How often do you administer drugs that have not been prepared and checked by you? (Sometimes: 1) (Never: 0)

8. How often do you take verbal messages? (Sometimes: 2) (Never: 0)

10. Are drugs stored within locked cabinets and cupboards? (Y: 0) (N: 1)

So you think you are a safe drug giver?

11. How often are drugs left out unattended? (Sometimes: 2) (Never: 0)

12. Is there efficient ordering and stock management which keeps stocks well in date etc? (Y: 0) (N: 2)

13.Do you feel able to question ALL staff including senior nurses/ medical staff? (Y: 0) (N: 2)

14. Is the responsibility of medication administration clearly retained by the nurse responsible for caring for the patient?. (Y: 0) (N: 1)

15. How often are drugs prepared before they are required? (Sometimes: 2) (Never: 0).

So you think you are a safe drug giver?

16. Are drug errors an acceptable risk? (Y: 2) (N: 0)

17. How often do you and your colleague calculate the dose independently before comparing answers? (Always: 0) (Sometimes: 1)

18. How often do you rely on your colleague to make the correct calculation instead of working it out yourself? (Sometimes: 2) (Never: 0)

19. How often do you and your colleague go together to identify the patient? (Always:0 ) (Never: 2)

20. How often do you check the dosage in the formulary when you are not sure? (Always: 0) (Never: 2)

Scores

If you have scored between 0-5

Very well done: on the whole your drug administration practice is very safe and you are an excellent role model for colleagues, share your good practice

Scores

If you have scored between 6-15

Be extra careful: your practice is not consistent, you should brush up on your technique before you make an error. Make sure you are familiar with the drug policy and look at techniques to avoid errors.

Scores

If you have scored between 16-37

This should ring alarm bells!! Your practice is really rather dangerous and your competence to administer drugs is questionable, seek help, pull your socks up!

Medication Errors

The medication administration observational audit highlighted several issues including– Inadequate space

– Distractions

– Interruptions

– Staff shortages

– Large range of drugs and doses used in some areas

– Similar packaging of drugs

– Tiredness as a result of long shifts

Medication Errors

– Some patients did not have identification bracelets

– Inadequate checking of identification labels

– One nurse checking two different prescriptions at the same time

– Second checker not checking the entire process

– Checking prescriptions and medications very quickly

– Calculations not being made independently by both nurses

Medication Errors

What percentage of incidents are reported by nursing staff?

Medication Errors

What percentage of incidents are reported by nursing staff?

95% of all medication related incidents are reported by nursing staff.

Medication Errors

What percentage of all reported incidents relate to medication errors?

Medication Errors

What percentage of all reported incidents relate to medication errors?

In 2003-2004 19% of all reported incidents relate to medication errors

Medication Errors

53% of all reported drug errors can be categorised as nurse checking errors.

Medication Errors

What percentage of incidents are graded as being of moderate or high significance?

Medication Errors

What percentage of incidents are graded as being of moderate or high significance?

Approximately 22% are graded as orange or red which is equivalent to 24 incidents per year or 2 incidents every month.

Medication Errors

Incident reporting is an important element of risk management.

Reporting of adverse events and near misses allows systems errors to be detected.

Review and implementation of new systems can prevent errors from re-occurring and near miss incidents becoming adverse events.

Medication Errors

ActivityImagine that you are the Clinical Governance

Facilitator.– Working in small groups read the following incident

reports.– What other information do you need to decide how to

proceed with this form?Grade the incident using the grading matrix.What recommendations would you make to

prevent this from re-occurring?

Example Medication Errors

“IV Morphine given by *** and checked by ***. Dose given was too much.”

Example Medication Errors

“At 20.30 I gave *** a 400 mls fluid bolus because she had not passed urine since 11.00 that morning when her catheter was removed. I forgot to set the volume limit and she got 540 mls.”

Example Medication Errors

“Frusemide IV infusion made up with 5% Dextrose due to patient having a high serum sodium. When changing infusion 22 hours later discovered that Frusemide is not compatible with Dextrose.”

Final Message to take homeDo’s and Don’tsDo be careful and allow sufficient timeDon’t allow yourself to be distracted or

rushedDon’t “short cut” the checking processDo check with the Dr/Pharmacist if unsure

and question colleagues however senior to you if you don’t agree

Do check that the correct patient receives the correct dose of the correct medication at the correct time, via the correct route.

Final Message to take homeDo’s and Don’tsDo report incidents and ‘near

misses’