1. By: Holly Cole & Brenda White NURS 450
Medication Errors
By: Holly Cole & Brenda White
NURS 450

2. Nurses & Medication Administration
Approximately 40% (roughly 16 hours per week) of a nurse’s clinical time is devoted to medication management
Adverse drug events (1.5 million are preventable) are the most frequently cited cause of significant harm and death among hospitalized patients
Actual or potential med errors can be caused by:
| job stress
| insufficient training or knowledge
| similar labeling & packaging
| interruptions during administration
Most common medication error is overdose

3. Medication Errors Defined
“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”
The National Coordinating Council for Medication Error Reporting and Prevention (2016)

4. Presentation Purpose & Learner Objectives
| Educate nurses on medication errors: how & why they occur
| Assess nursing environments & medication administration
| Provide recommendations for reduction in errors
Learning Objectives:
| State the 8 Rights of Medication Administration
| Discuss how & why medication errors occur
| Explain how medication errors impact patients
| Explain how medication errors impact nurses & their facilities
| Discuss ways to decrease rates of medication errors

5. 8 Rights of Medication Administration
Right Person
| Use at least 2 patient identifiers
Right Medication
| Verify medication label & order
Right Dose
| Identify strength of medication & calculate dose
Right Route
Right Time
| Verify time of last dose for PRN medication
Right Documentation
Right Reason
| Clarify why medication is prescribed
Right Response
| Desired effect/response

6. How & Why Errors Occur Common Errors: | incorrect dosage calculations
| renal/hepatic insufficiency (requiring dose change)
| incorrect drug, dose, or abbreviation
| atypical dose frequency
Why:
| knowledge deficit regarding drug therapy (new grads, inexperience)
| knowledge deficit regarding patient factors affecting therapy
| calculations, decimal points, unit/rate exchange factors (math skills)
| transcription errors: incorrect drug name, dose, or abbreviation
| interruptions during administration

7. Root Cause Analysis Personal/Individual Environment MEDICATION ERROR
Multiple Interruptions
Fatigue
Lack of confidence/skill set
Noise Level
MEDICATION
ERROR
Inadequate staffing levels
Knowledge of medications
Lack of communication
Insufficient skills training
Inadequate supervision/training
Education
Organization

8. When Errors Occur… Reporting of medication errors- Why?
| Prevent further harm/errors
| Reduce liability
| Monitor trends in errors
| Educate healthcare professionals
| Enhance safety
| Policy/procedure revision
| Notification of patients

9. Consequences of Medication Errors: Patients
Additional medical interventions
| medication reversal/antidotes
| EKG/ECHO
| lab-work & monitoring
Prolonged hospitalization
| medication errors injure approximately 1.3 million people yearly
Increased cost
| $4 million per hospital in additional costs
Death
| medication errors account for at least 1 death daily
(Food and Drug Administration, 2009)

10. Cost of medication errors
Annual cost of approximately 400,000 errors was $3.5 billion (in 2006)
Higher insurance premiums
Higher taxes
Lost time and wages

11. Consequences of Medication Errors: Staff
Loss of confidence
Fear of disciplinary action
|loss of license
|loss of job/position
Public humiliation
| Legal consequences
Hypervigilance
Serembus, J. F., Wolf, Z. R., & Youngblood, N. (2001, August). Consequences of Fatal Medication Errors for Health Care Providers: A Secondary Analysis Study. MedSurg Nursing, 10(4), 193. Retrieved from

12. Reduction of Errors-Recommendations
Medication reconciliation with patient/family upon admission
| encourage patients to have up-to-date drug list
Do-not-use abbreviation list
Error Prone Abbreviations
Look-alike, Sound-alike drug list
Bar-code scanning
| over 55% reduction in errors shown in some units
Electronic prescribing
| computerized physician order entry can reduce errors by more than one-half
Enhanced communication & education

13. Staff Improvement-Recommendations
Training programs: to improve nursing awareness & skills
| education & increasing knowledge
Optimizing medication policies: to improve medication management systems
| incompatibility charts, workflow improvements
Refining drug classification: to improve administration of drugs
| high-risk medication labels & storage
Enhance safety process for IV meds: to standardize administration
| dosage rates & compatibility
Supervising the process of medication administration: to ensure safety
| no-interruption zones

14. Conclusion
Approximately 40% (roughly 16 hours per week) of a nurse’s clinical time is devoted to medication management
Adverse drug events (1.5 million are preventable) are the most frequently cited cause of significant harm and death among hospitalized patients
Medication errors can occur for many reasons, many of them attributed to inexperience, knowledge deficits, or interruptions
Medication errors should always be reported in accordance with the facility’s protocol
Both staff and patients suffer from medication errors
Implementation of safety cultures, double checks, and education programs may help reduce errors and keep patients safer

15. Discussion Questions…
Many facilities are now using electronic medical records as a way to document, prescribe, and transmit medical information. With the implementation of the EMR, most medication administration records (MARs) are electronic as well. Bar-code scanning has been widely implemented to help increase safety with administration of medications. In your place of employment, what additional safety measures have been put into place to help reduce medication errors? In addition to discussing these safety measures, please also identify one NEW policy, procedure, or administration standard you feel would be helpful in preventing medication errors in your practice.
Medication errors happen for a variety of reasons.  It may be due to lack of medication knowledge, nursing fatigue, mislabeled medications, failure to read back an order to a physician, pharmacy dosing errors, giving medications via the wrong route, at the wrong time, and even to the wrong patient.  Many facilities have non-punitive reporting systems in place to report medication errors.  You are able to report the error either anonymously or you can choose to be named as the person reporting the error.  Does your facility have this type of system for reporting medication errors?  If so, do you feel this helps to curtail the number of medication errors, and do you feel that more errors are reported because it is non-punitive?  If your facility does not have this type of system, do you feel it would be beneficial?

16. References
Anderson, P., & Townsend, P. (2010). Medication errors: Don’t let them happen to you. American Nurse Today, 5(3), Retrieved from
Armitage, G., & Knapman, H. (2003). Adverse events in drug administration: a literature review. Journal of Nursing Management, 11(2), Retrieved from x/epdf.
Burgess, L.H., Cohen, M.R.., & Denham, C.R. (2010). A new leadership role for pharmacists: A prescription for change. The Journal of Patient Safety, 6(1), Retrieved from
Flynn, L., Liang, Y., Dickson, G.L., Xie, M., & Suh, D. (2012). Nurses’ practice environments, error interception practices, and inpatient medication errors. Journal of Nursing Scholarship, 44(2), search.proquest.com.libcat.ferris.edu/docview/ ?accountid=10825.
Food and Drug Administration. (2009). Medication Errors. Retrieved from
Food and Drug Administration. (2015). Safe Use Initiative. Retrieved from
Gallagher, T.H., Studdert, D., & Levinson, W. (2007). Disclosing harmful medication errors to patients. The New England Journal of Medicine, 356(26), Retrieved from
Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (Editors). (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press

17. References
National Coordinating Council for Medication Error Reporting and Prevention. (2016). What is a Medication Error? Retrieved from National Quality Forum. (2015). Patient Safety Retrieved from Orbæk, J., Gaard, M., Fabricius, P., Lefevre, R. S., & Møller, T. (2015). Patient safety and technology-driven medication–A qualitative study on how graduate nursing students navigate through complex medication administration. Nurse education in practice, 15(3), Retrieved from Serembus, J. F., Wolf, Z. R., & Youngblood, N. (2001, August). Consequences of Fatal Medication Errors for Health Care Providers: A Secondary Analysis Study. MedSurg Nursing, 10(4), 193. Retrieved from go.galegroup.com.libcat.ferris.edu/ps/i.do?id=GALE%7CA &v=2.1&u=lom_ferrissu&it=r&p=AONE&sw=w&as id=77ed29943f300c189b4e0a46b84074fa Wittich, C.M., Burkle, C.M., & Lanier, W.L. (2014). Medication errors: an overview for clinicians. Mayo Clinic Proceedings, 89(8), doi: /j.mayocp Xu, C., Li, G., Ye, N., & Lu, Y. (2014). An intervention to improve inpatient medication management: a before and after study. Journal of Nursing Management, 22, doi: /jonm.12231