nurs 221: quiz #2
MEDICATION ERROR (ME) OVERVIEW
1. What is Medication Error-Definition
2. Occurrence of Medication Error: STATS
3. Classification /Types of Medication Errors
4. Who makes Medication Error
5. High Alert/SALAD Drugs
6. Reducing Medication Error
7. Reporting Medication Error
8. Case Studies
9. Summary
MEDICATION ERROR DEFINITION:
any preventable event that may cause or lead to inappropriate medication use
or patient harm while medication is in the control of the health care
professional, patient, or consumer
GENERAL SOURCES OF MEDICATION ERRORS
1. Manufacturer
2. System Weakness
3. Provider
4. Dispenser
5. Administration
6. Other Staff
,7. Patient
CLASSIFICATION OF MEDICATION ERRORS
ERRORS → OMISSION (we didn't give medication at all, we missed a dose) /
COMMISSION (we did give the medication but something is wrong (dose,
patient, etc.))
OCCURRENCE OF MEDICATION ERROR
Human Factor: 90%
1. Performance: 29.8%
- 1. Overdose: 36.4
- 2. Wrong Drug: 16.2%
- 3. Wrong Route: 9.5%
2. Knowledge Deficit: 14.2%
3. Miscommunication: 15.8%
4. Drug Name Confusion: 15%
5. Miscalculation: 13%
PERFORMANCE ERROR
1. Wrong Patient
2. Wrong Drug
3. Wrong Dose
4. Wrong Route
5. Wrong Time
,6. Omitted Dose
7. Wrong dosage form, diluent, concentration, infusion rate
8. Wrong technique
9. Wrong duration (certain medications need time to infuse, chemo needs to
last a certain amount of time, blood transfusion in a certain number of hours)
10. Expired dose
11. Documentation
KNOWLEDGE DEFICIT
1. Particulars of a drug: PK, PD, MOA, SE, SDR
2. Order interpretation
3. Miscalculation
4. Drug preparation
5. Drug Name confusion - SALAD / LASA
6. Labeling
DISTRACTIONS / SOURCES
1. Phone calls
2. Unrelated conversations
3. Call lights
4. Change in patient condition
WORKLOAD
, 1. Nurse: Patient Ratio
2. Nurse: Student Preceptorship: Patient Ratio
3. Nurse: Nurse support
4. Other Assignments
STAFF EXPERIENCE / INEXPERIENCE
1. Student Nurse
2. New Hire Nurse
3. Staff from agency
STAFFING ISSUES
1. Ill/ Sick calls
2. Administrative decision
3. Unforeseen emergency
SHIFT CHANGE EVENTS
1. Patient transfer
2. Shift report
EMERGENCY SITUATIONS
1. Change in patient condition
2. Patient incident (falls)
MEDICATION ERROR (ME) OVERVIEW
1. What is Medication Error-Definition
2. Occurrence of Medication Error: STATS
3. Classification /Types of Medication Errors
4. Who makes Medication Error
5. High Alert/SALAD Drugs
6. Reducing Medication Error
7. Reporting Medication Error
8. Case Studies
9. Summary
MEDICATION ERROR DEFINITION:
any preventable event that may cause or lead to inappropriate medication use
or patient harm while medication is in the control of the health care
professional, patient, or consumer
GENERAL SOURCES OF MEDICATION ERRORS
1. Manufacturer
2. System Weakness
3. Provider
4. Dispenser
5. Administration
6. Other Staff
,7. Patient
CLASSIFICATION OF MEDICATION ERRORS
ERRORS → OMISSION (we didn't give medication at all, we missed a dose) /
COMMISSION (we did give the medication but something is wrong (dose,
patient, etc.))
OCCURRENCE OF MEDICATION ERROR
Human Factor: 90%
1. Performance: 29.8%
- 1. Overdose: 36.4
- 2. Wrong Drug: 16.2%
- 3. Wrong Route: 9.5%
2. Knowledge Deficit: 14.2%
3. Miscommunication: 15.8%
4. Drug Name Confusion: 15%
5. Miscalculation: 13%
PERFORMANCE ERROR
1. Wrong Patient
2. Wrong Drug
3. Wrong Dose
4. Wrong Route
5. Wrong Time
,6. Omitted Dose
7. Wrong dosage form, diluent, concentration, infusion rate
8. Wrong technique
9. Wrong duration (certain medications need time to infuse, chemo needs to
last a certain amount of time, blood transfusion in a certain number of hours)
10. Expired dose
11. Documentation
KNOWLEDGE DEFICIT
1. Particulars of a drug: PK, PD, MOA, SE, SDR
2. Order interpretation
3. Miscalculation
4. Drug preparation
5. Drug Name confusion - SALAD / LASA
6. Labeling
DISTRACTIONS / SOURCES
1. Phone calls
2. Unrelated conversations
3. Call lights
4. Change in patient condition
WORKLOAD
, 1. Nurse: Patient Ratio
2. Nurse: Student Preceptorship: Patient Ratio
3. Nurse: Nurse support
4. Other Assignments
STAFF EXPERIENCE / INEXPERIENCE
1. Student Nurse
2. New Hire Nurse
3. Staff from agency
STAFFING ISSUES
1. Ill/ Sick calls
2. Administrative decision
3. Unforeseen emergency
SHIFT CHANGE EVENTS
1. Patient transfer
2. Shift report
EMERGENCY SITUATIONS
1. Change in patient condition
2. Patient incident (falls)
