1. IMPROVING DRUG ERROR REPORTING IN CRITICAL CARE UNITS AMONG NURSES
PRESENTER: SAMUEL NZAU
KENYATTA NATIONAL HOSPITAL
DATE: 5TH OCTOBER 2017

2. OUTLINE Background information Sources of medication errors
Contributing factors to medication errors
Approaches to reduce drug errors
Reporting drug errors

3. If you saw this would you fly?
Breaking news….
Airlines expect 1-2 jets to crash
daily
Over 1000 deaths expected weekly

4. What if a patient saw data like this?
44, ,000 deaths
Annually occur due to
Medication errors

5. BACKGROUND
Safety is a global concept that encompasses efficiency, security of care, reactivity of care givers, satisfaction of patients and relatives. Patient’s safety is the major target to improve health care (Garrouste-Orgeas, Philippart, Bruel, Max, Lau & Misset, 2012)

6. BACKGROUND CONT.
Medication error is defined as 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 (Salmasi, Khan, Hong, Ming, Wong, 2015)

7. BACKGROUND CONT.
Medication error includes medications: Omitted, given at the wrong time, given to the wrong patient, the wrong dose, the wrong medication, the result of a transcription error, given to a patient with a known allergy, repeated without an order, given by the wrong route, and discontinued without an order
( Khowaja et-al 2007)

8. BACKGROUND CONT.
Internationally the rate of drug errors occur in almost one out of every five doses (McBride-Henry & Foureur M, 2006)
Medical errors are one of the most common threat to patient safety
Assuring patients safety is of high priority for medical practitioners ( Toruner & Uysal, 2012)

9. BACKGROUND CONT.
Studies done in Ethiopia ICU by Agalu, Ayele, Bedada and Woldie (2012) and in Kenya at KNH by Ndambuki, Odhiambo, Chenge & Mirie (2013) showed that drug errors are more common in critical care areas due to the complexity of the units and the amount of work load and stress levels

10. BACKGROUND CONT.
Study by Toruner and Uysal, (2012), showed that proper training and reporting reduces the rate of drug errors in clinical set ups

11. CONT…
It is recommended that medication errors need to be properly documented and reported to the relevant supervisor to allow steps be taken to reduce such errors ( Toruner & Uysal, 2012)
Reporting drug error could avoid death but could also empower nurses

12. SOURCES OF MEDICATION ERRORS
Inaccurate recording and transcribing orders
Unclear or erroneous labeling of drugs
Improper patient identification
Incomplete delivery of drugs
Verification errors
Time and performance pressure
( Toruner & Uysal, 2012)

13. CONTRIBUTING FACTORS
Lack of knowledge of prescribed drug, its recommended dose and of the patient details
Illegible handwriting
Inaccurate medication history
taking
Nomenclature causes ( LASA)
(Ndambuki, Odhiambo, Chege and Mirie, 2013)

14. CONT.. Inappropriate use of decimal points Use of abbreviations
Use of verbal orders
(Ndambuki, Odhiambo,
Chege and Mirie, 2013)

15. APPROACHES TO REDUCE DRUG ERRORS
Proper patient identification
Correct dosage calculation
Minimizing interruptions
during drug administration
Ensuring that all the rights of
drug administration are adhered to
( Toruner & Uysal, 2012)

16. CONT.. Proper verification Proper documentation
( Toruner & Uysal, 2012)

17. REPORTING MEDICATION ERRORS
Making an error does not make you a bad nurse. Excellent practitioners, pharmacists, physicians and nurses make mistakes
Reporting errors should not be used for punitive issues but to improve practice and patient safety (Ndambuki, Odhiambo, Chege and Mirie, 2013)

18. CONT..
There are different tools used to report drug errors: These are online reporting tool and the printed reporting form
There is a lot of under reporting and this is associated with several factors to include lack of confidentiality
(Camire, Moyen and Stelfox, 2009)

19. DRUG ERROR REPORTING AT KNH
We have a tool in the institution which aids in reporting this errors
It is subdivided into 5 stages of the medication cycle
It contains a disclaimer that “ This is a blame free reporting tool”

20. CONT.. There is lack of data due to under reporting
Measures to enhance the reporting of drug errors are being instituted to improve the same in the institution through CME and reassurance

21. REASONS FOR UNDERREPORTING
A desk survey conducted revealed that:
Fear of reaction from managers and coworkers
Fear of punishment
Low self-esteem
Organizational factors
Potential termination from job

22. REFERENCES
Agalu,A., Ayele, Y., Bedada, W. & Woldie, M. (2012). Medication administration errors in an intensive care unit in Ethiopia. International Archives of medicine 5(15). Dessie.Ethiopia.
Garrouste-Orgeas, M., Philippart, F., Bruel, C., Max, A., Lau, N. & Misset, B. (2012). Overview of medical errors and adverse events. Annals of Intensive Care 2 (2). Paris, France. Doi: /
McBride-Henry, K.& Foureur, M (2006). Medication administration errors: understanding the issues. Australian journal of Advanced Nursing 23(3) pdf

23. REFERENCES
Ndambuki, J., Odhiambo, E., Chege, M. & Mirie, W. (2013). Factors influencing quality management of medication by Nurses at Kenyatta National Hospital paediatric wards, Nairobi, Kenya. Journalof Biology, Agriculture and health care 13(18).S3.amazonaws.com/academia.edu.documents/ /
Toruer.E, & Uysal G (2012). Causes, reporting and prevention of medication errors from a pediatric nurse perspective. Australian journal of advanced nursing 29(4). Ankara, Turkey. < mmary;dn= ;res=IELHEA>ISSN: