2 IntroductionMedication 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.
3 Medication ErrorsA 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.
4 The First Stage of Medication Errors Prescribing or ordering medicationErrors are most prevalent when:Choosing a medicationChoosing its dosageChoosing its schedule
5 The Second Stage of Medication Errors Dispensing of medicationIt is important to double-check medications against:A medication administration record (MAR)Another medication order
6 The Third Stage of Medication Errors Administration of medication and patient monitoringThese are the responsibilities of the health care professional.
7 Additional Information The most common medication error concerns dosageIncreased use of OTC drugs and herbals contribute to medication errorsMedication errors must be reported as soon as they are noticed
8 Kasco Sandor / Shutterstock Figure Nearly half of fatal medication errors occur in patients older than 60 years of age.
9 Why Medication Errors Occur Use of incorrect abbreviationsMiscommunicationMissing informationLack of appropriate labelingEnvironmental factorsPoor management
10 Causes of Medication Errors Wrong patientIncorrect routeIncorrect drugIncorrect dose
11 Causes of Medication Errors Incorrect timeIncorrect techniqueIncorrect information on the patient chart
12 Reducing Medication Errors Employ an adequate number of staffUse standardized measurement systemsUse error-tracking systems
13 Reducing Medication Errors Review of original drug ordersCompile medication profilesProvide suitable work environments
14 Reducing Errors in Health Care Facilities Automation allows drug storage cabinets to maintain an accurate inventory.Risk management departments minimize errors and examine risks.
15 Reducing Errors in Health Care Facilities Avoid:Expired medicationsTransfer of medications between containersOverstockingDangerous abbreviationsReference materials that are not up to date
16 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.
17 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
18 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.
19 Documenting Medication Errors Root cause analysis of documentation may be used to prevent future errors from occurring and to reduce potential risks.
20 Strategies Assessment of patients’ use and knowledge of medications Planning of medication therapy and understanding of every step that will occur
21 StrategiesImplementation of all proper procedures to ensure accurate use and monitoringEvaluation of correct outcomes and adverse effects
22 Categories of Medication Errors A – having capacity to cause errorsB – occurred errors that did not reach patientC – errors that reached patient without harmD – errors that could have caused harmE – errors that might have caused harm and required intervention
23 Categories of Medication Errors F – errors that might have caused harm and required hospitalizationG – errors that might have caused long-term harmH – errors that required intervention to sustain lifeI – errors that might have caused the patient’s death
24 Reconciliation of Medications Polypharmacy is receiving multiple medications, sometimes for the same condition, that have conflicting actionsIt is most common in older patientsKeeping track of patient medications as health care providers are changed is called medication reconciliation