1. Quarterly Medication Error Data April 2006

2. Quarterly Error Report - Review Medication Error data based upon Safety Reports No report = No data Greater than 51% of RN’s report they have made a medication error in the past 12 months.* Only 5% of significant errors are reported. * Reports are completed* Error is life-threatening Medication Vital to Patient’s Treatment *Lowe, Debra K and Belchre, Jan V. 2002. Reporting medication Errors Through Computerized Medication Administration. CIN: Computers, Informatics Nursing. 20:5. 178-183.

3. Error Stage for Serious Medication Errors Leape, JAMA 1995 OEeMAR

4. Quarterly Error Report 10/2005 – 12/2005 Ordering: 20 (11%) Dispensing: 10 (5.5%) Administration: 144 (83%) Total: 174

5. Quarterly Error Report 1/2006-3/2006 Ordering: 7 (4.6%) Dispensing: 17 (11.4%) Administration: 125(84%) Total: 149

6. Quarterly Error Report 10/2005 – 12/2005 1/2006 – 3/2006

7. Emerging Themes System only as good as the user that drives it. Confirmation of Schedules. Alaris and PCA Pump Programming. Failure to read Instructions

8. Top Nine

9. Error Types 1/2006 – 3/2006

10. Reported Causes of Error

11. eMAR Error Prevention Data January 2006-March 2006 Total Patients13,177 Total Administrations1,198,763 Wrong Drug Intercepted18,489 Wrong Patient Intercepted484 Expired Medications Intercepted2079

12. Medication Errors Order for Robitussin with codeine Pharmacy dispensed Robitussin DM Emar scan indicated “wrong med” Nurse consulted other staff who told her “it never scans right” Nurse gave the Robitussin DM as a manual administration and indicated “bar code unreadable” as reason for manual entry

13. Take Away Message When medications do not scan properly, call pharmacy.

14. Medication Error Nurse had 2 bags (lopressor and dilaudid) of medication for her 2 patients in her hand. Scanned dilaudid. Hung lopressor.

15. Medication Errors Patient ordered for 250 mg of Erythromycin via G tube. Nurse administered 250 mL. Error discovered when nurse called pharmacy for more medication for next dose.

16. Medication Error Two IV bags hanging at bedside – Heparin and NS. Hung antibiotic secondary bag and mistakenly infused the Heparin bag instead.

17. Medication Error - Scheduling

18. Fentanyl dose changed from 100 mcg to 300 mcg. Default dosing indicated first dose for the next day. Nurse did not change schedule. Patient waited until the next day for increased dose.

19. Questions? Please email Carol Luppi Cluppi@partners.org