8 Medication Errors and Prevention

Introduction Medication and medical errors occur throughout the United States. The system needs to be improved to afford patients with true quality care. Health professionals, patients, and families must work together and become educated about reducing all types of medical errors.

Medication Errors A medication error is the inappropriate or incorrect administration of a drug that should be preventable through effective system controls. Medication errors result in pain, injury, and death. Medication errors usually occur more frequently than they are reported.

The First Stage of Medication Errors Prescribing or ordering medication Errors are most prevalent when: Choosing a medication Choosing its dosage Choosing its schedule

The Second Stage of Medication Errors Dispensing of medication It is important to double-check medications against: A medication administration record (MAR) Another medication order

The Third Stage of Medication Errors Administration of medication and patient monitoring These are the responsibilities of the health care professional.

Additional Information The most common medication error concerns dosage Increased use of OTC drugs and herbals contribute to medication errors Medication errors must be reported as soon as they are noticed

Kasco Sandor / Shutterstock Figure 8-1 Nearly half of fatal medication errors occur in patients older than 60 years of age.

Why Medication Errors Occur Use of incorrect abbreviations Miscommunication Missing information Lack of appropriate labeling Environmental factors Poor management

Causes of Medication Errors Wrong patient Incorrect route Incorrect drug Incorrect dose

Causes of Medication Errors Incorrect time Incorrect technique Incorrect information on the patient chart

Reducing Medication Errors Employ an adequate number of staff Use standardized measurement systems Use error-tracking systems

Reducing Medication Errors Review of original drug orders Compile medication profiles Provide suitable work environments

Reducing Errors in Health Care Facilities Automation allows drug storage cabinets to maintain an accurate inventory. Risk management departments minimize errors and examine risks.

Reducing Errors in Health Care Facilities Avoid: Expired medications Transfer of medications between containers Overstocking Dangerous abbreviations Reference materials that are not up to date

Results of Medication Errors In hospitals, medication errors are the most common causes of morbidity and preventable death. Also, financial penalties may be assessed, and legal actions may result. Thorough investigation and documentation lead to prevention of future errors.

Reporting Medication Errors Health care professionals should use the FDA’s MedWatch program to report medication errors. Other related organizations include: National Coordination Council for Medication Error Reporting and Preventing (NCC MERP) Institute for Safe Medication Practices (ISMP) The Joint Commission

Documenting Medication Errors The patient’s medical record should be updated with complete information about medication errors. Incident reports (occurrence reports) should also be completed for risk management.

Documenting Medication Errors Root cause analysis of documentation may be used to prevent future errors from occurring and to reduce potential risks.

Strategies Assessment of patients’ use and knowledge of medications Planning of medication therapy and understanding of every step that will occur

Strategies Implementation of all proper procedures to ensure accurate use and monitoring Evaluation of correct outcomes and adverse effects

Categories of Medication Errors A – having capacity to cause errors B – occurred errors that did not reach patient C – errors that reached patient without harm D – errors that could have caused harm E – errors that might have caused harm and required intervention

Categories of Medication Errors F – errors that might have caused harm and required hospitalization G – errors that might have caused long-term harm H – errors that required intervention to sustain life I – errors that might have caused the patient’s death

Reconciliation of Medications Polypharmacy is receiving multiple medications, sometimes for the same condition, that have conflicting actions It is most common in older patients Keeping track of patient medications as health care providers are changed is called medication reconciliation