1. 8
Medication Errors and Prevention

2. Introduction
Medication 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 Errors
A 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 medication
Errors are most prevalent when:
Choosing a medication
Choosing its dosage
Choosing its schedule

5. The Second Stage of Medication Errors
Dispensing of medication
It 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 monitoring
These are the responsibilities of the health care professional.

7. Additional Information
The most common medication error concerns dosage
Increased use of OTC drugs and herbals contribute to medication errors
Medication 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 abbreviations
Miscommunication
Missing information
Lack of appropriate labeling
Environmental factors
Poor management

10. Causes of Medication Errors
Wrong patient
Incorrect route
Incorrect drug
Incorrect dose

11. Causes of Medication Errors
Incorrect time
Incorrect technique
Incorrect information on the patient chart

12. Reducing Medication Errors
Employ an adequate number of staff
Use standardized measurement systems
Use error-tracking systems

13. Reducing Medication Errors
Review of original drug orders
Compile medication profiles
Provide 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 medications
Transfer of medications between containers
Overstocking
Dangerous abbreviations
Reference 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. Strategies
Implementation of all proper procedures to ensure accurate use and monitoring
Evaluation of correct outcomes and adverse effects

22. Categories of Medication Errors
A – having capacity to cause errors
B – occurred errors that did not reach patient
C – errors that reached patient without harm
D – errors that could have caused harm
E – errors that might have caused harm and required intervention

23. Categories of Medication Errors
F – errors that might have caused harm and required hospitalization
G – errors that might have caused long-term harm
H – errors that required intervention to sustain life
I – 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 actions
It is most common in older patients
Keeping track of patient medications as health care providers are changed is called medication reconciliation