The Practical Nurses Role in Preventing Medication Errors 8th EditionTextbook Chapter 9 Rev KBurger 0608

Medication Errors 10 percent to18 percent of hospital injuries attributed to medication errors 44,000 to 98,000 people die in U.S. hospitals annually due to medication errors

Medication Errors Effects of medication errors Increase length of stay Increased cost Patient disability Death Nurse’s personal and professional status, confidence, and practice

Nursing Responsibilities Legal and Ethical Nurses are liable for their actions, omissions, and for those duties they may delegate to others. They are personally responsible…legally, morally and ethically…for every drug they administer. Drugs can help or harm. Nurses, physicians, and clinical pharmacists are held legally responsible for safe and therapeutically effective drug administration. no matter who actually prescribed it. All members of a health team may be held liable for a single injury to a client. Ethical considerations: Each nurse needs to identify his/her own concept of ethical and moral correctness and responsibility. The principles of malfeasance (the duty to do no harm) beneficence (the duty to do good), client autonomy, truthfulness, justice, fidelity, (faithfulness to one's obligations), and integrity(being true to one's word) are the cornerstones for ethical decision-making.   Ethics- Nursing organizations have adapted similar codes of ethics that can serve as guides for the development of one's own code. The client's rights as defined by these codes of ethics are to promote health, prevent illness, restore health, and alleviate suffering. For example, a patient has every right to know necessary information about a drug he or she is receiving and to refuse to take it after having been given an explanation, no matter what the consequences of that decision may be for the patient.

Nursing Responsibilities Obtaining current knowledge base of drugs Referring to authoritative sources in professional literature (less than 5yrs old) Questioning a drug order that is unclear or that appears to contain an error Refusing to administer a drug if there is a reason to believe it will be harmful. Performing correct techniques and precautions Monitoring client response and documenting drug effects Patient and family education Current Knowledge:Personal preparation: understanding the effects of a particular class of drugs and the ability to analyze and synthesize information. Correct tech: Administration of medications: The techniques and policies for this responsibility will be taught in the NR 20 laboratory. Patient and family education: Answering questions: "Why does the doctor keep changing the medication dose?"

Nursing Responsibilities continued Know Information about the medication Action – side effects – appropriate dose Age specific considerations – routes Know Information about the client What other medications are they taking ALLERGIES or other problems w/ meds Gag reflex – Impaired swallowing Dietary and/or Fluid restrictions Cultural and/or religious influences Genetic factors Vital signs Lab values – renal & liver function / protein & albumin Age Pregnant/breast feeding

Nursing Responsibilities continued Using correct techniques of preparation and administration to deliver medications safely. Monitoring the client for therapeutic and non-therapeutic effects of the drug Client education for safe and accurate self-administration of the drug. Implementing: intervene obtain new order for liquid meds for pt. Eval: able to swallow meds with out difficulty

Legal Controls in Pharmacology Purpose and Scope of Legal Controls: Protect public health and safety Laws govern testing, production, distribution, prescription and the administration of drugs.

Federal Medication Laws 1906 Pure Food & Drug Act Disclosure of dangerous ingredients 1912 Sherley Amendment No fraudulent claims of action 1914 Harrison Narcotic Act Established regulations for narcotics 1938 Food,Drug,CosmeticAct Drugs must be tested and proved safe 1952 DurhamHumphrey Amendment Established list of drugs needing RX 1962 Kefauver-Harris Amendment Drugs must be proven effective 1970 Controlled Substances Act Strict controls on distribution *** 1978 Drug Regulation Reform Act Shortened drug investigation time

***Controlled Substance Act Designed to promote treatment and prevention of drug dependence Established controls such as: -Prescribers are registered with the DEA. A registry number is issued to each person and is renewed annually. -Complete written records of all drugs prescribed must be kept for two years. Pharmacists record each sale in triplicate. Schedule II drug prescriptions cannot be renewed. -DEA (Drug Enforcement Agency) monitoring Health care agencies must establish policies to comply with Federal law. . Every druggist, nurse practitioner, physician, dentist, podiatrist, veterinarian or hospital selling or prescribing DEA- Drug enforcement agency

Controlled Substance Act - continued -All units have a record of every controlled drug on the unit and two nurses at the change of every shift count all drugs. -All controlled drugs are stored using a double lock system. Keys to medication areas are under the control of nurses on the unit. -Discarding of controlled substances must be witnessed by another nurse -Written renewal orders are required every 72 hours for narcotics and schedule II & III drugs. Discarding medications need a an RN to witness waste discarded. (Down the drain)

Control Schedule Drugs with a significant potential for abuse are classified into 5 categories or schedules: Schedule I: highest potential for abuse Illicit drugs (Heroin, LSD, Marijuana) Schedule II: (Morphine, Dilaudid) Schedule III: (Vicodin, Meperidine) Schedule IV: (Valium, Xanax) Schedule V: lowest potential for abuse (OTC cough suppressant w/codeine) I heroin, LSD, pot II morphine, cocaine III steroids, codeine IV Valium, Xanax V OTC, cough medicines with codeine

Drug Information Resources Agency pharmacists are an appropriate resource for obtaining drug information on the job.  Nursing drug handbooks: contain drug information along with nursing considerations. Physician's Desk Reference (PDR) Contains manufacturer's descriptions (package inserts) which are written using FDA standards, but may be slanted in favor of the drug being described. Package Inserts: Required by law for insertion with each new drug and must include a description, indications, precautions, dosage, and contraindications.  Electronic databases and Internet  

Adverse Drug Events (ADE) An undesirable occurrence related to administration of or failure to administer a prescribed medication. General term that includes all types of clinical problems encountered regarding medications including: - adverse drug reactions (ADRs) adverse effects allergic reaction idiosyncratic reaction -medication errors (MEs)

Adverse Drug Reaction ADR Any unexpected, undesired or excessive response to a medication given in therapeutic dosages) that results in: - temporary or serious harm or disability - admission to hospital, higher level care or prolonged stay - death

Adverse Drug Reaction continued Adverse Effects: -Expected side effects (ie stomach upset) -Dose-related reactions (ie liver or renal impairement, geriatric and/or pediatric considerations) -Drug/Drug or Drug/Food interactions (ie potentiation of drugs by another drug, or drug not absorbed well with food)

Adverse Drug Reaction continued Allergic Reaction: -Hypersensitivity ( ie: rash, anaphylaxis) Idiosyncratic Reaction: -abnormal and unpredicted response specific to an individual (ie: confusion and antibiotics)

Nursing Measures to Prevent Medication Errors Order interpretation, reconciliation, and confirmation Never assume anything about a drug order. CLARIFY, CLARIFY, CLARIFY Make sure medication orders contain all (7) parts Minimize use of verbal or telephone orders. If used, spell all drug names and repeat to confirm ( NOT LPN Scope) Check Medication Administration Records (MAR) to the original prescriber order as per agency protocol.

Nursing Measures to Prevent Medication Errors Safe Medication Administration USE THE SIX RIGHTS Right drug Right route Right patient Right dose Right time Right documentation

Right Patient Correctly identify patient prior to medication administration using at least (2) identifiers. Compare medical record number (MRN) on client armband with medication administration record (MAR) Ask the patient to state his name & DOB Compare picture to patient if available Technological advances to prevent errors Bar-coding

Right Patient Tell patient at time of administration what medication and dosage is being administered. Briefly explain therapeutic use of each medication Patient may question drug or dosage Re-confirm the drug order in chart and MAR Provides an opportunity to do medication teaching

Right Drug The (3) Checks Check medication label 3X On first contact with drug; when removing from medication box Prior to measuring Pouring, counting, or withdrawing Just prior to administration; when returning to medication box

Right Drug Be aware of distractions Do not multitask during drug administration Use bar-coding scanning when available Be knowledgeable about the drug’s actions, indications, and contraindications Be extremely vigilant about known HIGH ALERT MEDICATIONS Be alert to Look-a-like , Sound-a-like medications Do not accept Drug Name Abbreviations (IE MS for Morphine Sulfate )

HIGH ALERT MEDICATIONS Sound-a-like Look-a-like DRUGS ISMP List of High-Alert Medications HYPERLINK Top (5) drugs involved in harmful errors PINCH Potassium Insulin Narcotics Coumadin Heparin ISMP List of Confused Drug Names HYPERLINK Example: Tegretol versus Toradol (anticonvulsant versus antiinflammatory) Paxil versus Plavix (antidepressive versus antiplatelet) Use TALL-MAN letters Know both generic and trade names of drugs

Right Route Consult a drug information source to confirm correct route Do not accept incorrect abbreviations: sq or sc – WHAT IS PREFERRED? JCAHO Do not Use List Example: Be careful of: IVP versus IVPB

Right Route May need to change or clarify forms or routes of the drug for safe medication administration NPO status Client inability to swallow pills Nasogastric or surgically inserted tubes Time-released or enteric-coated medications

Right Time Order should include frequency of administration Administer medications within 1 hr of prescribed time ( or per facility guidelines) Use safe abbreviations Do not accept: QD or QOD WHAT IS PREFERRED???

Right Dose Carefully read and clarify drug orders Do not accept illegible handwriting Do not accept leading or trailing zeroes Do not accept U or IU WHAT IS PREFERRED? Recheck labels 3 times!

Right Dose Have two nurses double-check high alert medications Consult drug references Consider developmental age of client Accurate dosage calculations

Right Documentation Document IMMEDIATELY after administration NEVER DOCUMENT BEFORE!!! Omitting documentation can result in over or undermedication

Ethical Considerations Respect of patient rights Vigilant patient advocacy Maintenance of knowledge and skills Dedication to improvements in practice Notification of patients regarding errors Whistle-blowing

Genetic Factors Age-related Factors: Pediatric- -absorption, distribution, metabolism, excretion differences - weight based dosing Geriatric - decreased body fat, lean muscle, water - decreased plasma proteins - diminished GI motility and absorption - slower liver and kidney function Inherited Factors: Slow versus Fast Acetylators differences in metabolism of drugs (IE: Asian Americans need lower doses of the antiaxiety drug Haldol) Known Genetic group differences (IE: African Americans respond better to CCB drugs for hypertension)

Cultural Considerations Varying health beliefs and practices Folk and/or home remedies Religious practices Dietary practices RESPECT for client’s cultural context