Susan M Cleveland BSN, RN, WCC, CDPDirector of Nursing Services for Institutional Care Pharmacy

Tiffin and Mason, OH; Sharpsville, PA

List some common medication errors and associated regulatory deficiencies.

Identifying administrative supports for a successful medication pass.

Describe the pharmacist role in reducing medication errors.

Discuss medication administration processes to prevent errors.

An error occurs when the preparation or administration of a drug is not done in accordance with:

◦ Physician’s orders

◦ Manufacturer’s specifications

◦ Accepted professional standards and principles

Causes discomfort or jeopardizes safety of the resident

Guidelines for determining Significance

◦ Resident Condition

◦ Drug Category

◦ Frequency of Error

Illegible handwriting

Transition related

Similar packaging or labeling

Incorrect selection from a computerized product list

“Confirmation Bias”

Addition of Suffixes

Transcription errors to the MAR

Lack of knowledge of the drug

Lack of Patient Information

Violation of the rules

Faulty Identity Checking

Infusion Pump / Parenteral delivery problems

Inadequate monitoring

Drug Stocking & Delivery problems

Preparation Errors

USP Quality Review.

www.usp.org/reporting/review/qr66.pdf

Institute of Safe Medication Practices: http://www.ismp.org/Tools/confuseddrugnames.pdf

Zyrtec®Zantac®

Prilosec®Plendil®

Neoral®Nizoral®

Lomotil®Lamisil®

Fosamax®Flomax®

Cardura®Cardene®

LorazepamAlprazolam

Accutane®Accupril®

F329 Unnecessary drugs F332/333 Med errors F371 Sanitary conditions F385 Physician services F425 Pharmacy services F431 Storage of drugs/biologicals F441 Infection Control F501 Medical director F524 Clinical records F516 Confidentiality/Safety of

records

F157 Notification of change

F164 Privacy/Confidentiality

F241 Dignity

F272 Comprehensive assessment

F279 Comprehensive care plan

F281 Professional standards

F309 Quality of care

F323 Accidents/supervision

F325 Acceptable parameters F328 Special needs

Handwriting

Lack of specificity

EMR related errors

Failure to review

Failing to identify the symptoms the new

Lack of physician-physician handoff communication

Covering physicians order medications

Delivery issues

Expired medications in E-box, refrigerator

Dispensing errors◦ Medication

◦ Dose

Failure to identify issues:◦ Laboratory monitoring

◦ Drug-drug interactions

◦ Allergies

◦ Duplicate categories of medications

Frequent Distractions/Care Changes

Communication between disciplines

Failure to identify medication diversion

Inadequate attention to the role of the nurse

Lack of support/resources/supervision

Pharmacy provider does not include medication pass observations

Failure to follow “rights”

Failure to assess vital signs

Failure to monitor laboratory

Failure to assess resident’s condition

Dose omissions, “holds,” crushing

Tracking and reporting systems

Foster positive relationships

Establish interruption priorities

Establish universal cart set-up

Provide adequate tools and training

Establish a list of medications not needed after hospitalization

Do not accept “continue previous orders”

Reconcile medications

Verify admission orders

Request information early

Provide feedback to hospital

Reduce polypharmacy

Ensure proper monitoring

Medication scheduling

Trend errors

Education

Medication reconciliation

Pre-admission med list

Write accurate admission orders

Reconcile all variances

Provide continuing support and maintenance

Verbal orders

Enunciate slowly and distinctly

State numbers like pilots

Spell out difficult drug names

Specify concentrations

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

U

Ug

Q.D.

Q.O.D

SC

SQ

TIW

D/C

DC

HS

cc

AU, AS, AD

Error Prone Abbreviation List: http://www.ismp.org/Tools/errorproneabbreviations.pdf

Placing a zero after a decimal point ◦ example = 1.0 mg correct = 1 mg

Placing no zero before decimal dose ◦ example = .5 mg correct = 0.5 mg

Review MAR

Prepare medications

Do not borrow

Inspect medication for expiration date and/or contamination

Compliance with Nursing Standards

5 Rights of Medication Administration:

Right Drug

Right Dose

Right Route

Right Patient

Right Time

60 minutes before or after scheduled time

Before meals is up to15-30 minutes before meals

With meals can be up to 30 minutes after

After meals is usually up to 60 minutes after

Stay with the resident and monitor for:

Desired therapeutic effect of the medication,

Lack of evidence of therapeutic effect,

Side effects, adverse drug reactions, especially those severe enough to stop

the medication and allergic reactions.

Antipsychotics

Anticoagulants

Diuretics

Antiepileptic

Never touch

Do not crush list

Glove use

Mixing parameters

Sublingual or buccal

Shake medication well

Pour into graduated cup

Pour away from label

Never pour back into the bottle

Rinse viscous liquids

Store separately

Wash hand with soap and water after administration

More than one drop preparation given 5 minutes apart

Avoid touching dropper to mucus membrane

Shake suspensions before administration

Handwashing and glove application

Remember privacy rights prior to exposing the tube

Check placement of NG or G-Tube prior to giving meds

Flush enteral feeding tube before and after meds given

Wear gloves

Drape resident

Inspect skin

Shake lotions/sprays

Apply dressings

Reposition

Proper disposal

Handwashing

Shake MDI’s well, and position correctly

Wait 1 minute before giving next puff of MDI

Wait 5 minutes between puffs or as ordered

Rinse mouthpiece and wash hands

Mix Insulin correctly

Pens – scrub the hub

Storage and dating

Multi-use equipment

Provide adequate fluids with medications

To administer specific medications with food and antacids

Computers may help decrease the risk of confirmation bias.

Software alert pharmacists during the prescription adjudication

process.

Administer medications that are properly labeled.

Know the appropriate storage requirements.

Apply ongoing patient monitoring for effects.

Be knowledgeable about medication indications, precautions, contraindications,

expected outcomes

Administer medications that are properly labeled

Know the appropriate storage requirements of medications

Apply ongoing patient monitoring for desired/undesired effects of medication

Clarify incomplete, illegible, or any order of concern

Have knowledge of medication administration devices

Have adequate access to patient information (history, allergies, prognosis)

Universal cart set-up throughout building

Cart set up prior to pass

Food and beverages dated, labeled, closed container

Only authorized staff members have access to keys

Have cart in direct line of vision

Bar coding labels

Minimizing drug name confusion

Drug labeling

Error tracking and public education

1. Institute for Safe Medication Practices. http://www.ismp.org/default.asp. (Accessed March 3, 2017).

2. Institute for Safe Medication Practices. List of error-prone abbreviations, symbols, and dose

designations. 2015. http://www.ismp.org/Tools/errorproneabbreviations.pdf. (Accessed March 3,

2017).

3. Institute for Safe Medication Practices. http://www.ismp.org/Tools/confuseddrugsnames.pdf.

(Accessed March 3, 2017)

4. Institute for Safe Medication Practices. Residents vulnerable to harmful medication errors during

transition from hospital to long term care facility. 2013.

http://www.ismp.org/NEWSLETTER/longtermcare/issues/LTC201307.pdf. (Accessed march 31, 2017).

5. Stefanacci, Richard G DO, MGH, MBA, AGSF, CMD. Preventing medication errors. Managed HealthCare

Connect. 2006 ALTC (updated 2009)

6. Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.