1. Quarterly Medication Error Data January 2006

2. Quarterly Error Report 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. Emerging Themes eMAR System only as good as the user that drives it. Team double-checks not being performed Physician and Nurse check patients’ allergies Pharmacist default Times of First Dose not verified / corrected Time of Next Dose not verified By passing Reconciliation Prompt Not documenting pain medication administrations

6. Top Nine

7. Medication Errors Two nurses double-checked red syringe of chemotherapy then placed syringe in refrigerator. Nurse came back and retrieved red syringe from refrigerator and administered med to patient. Patient received wrong drug.

8. Medication Error Medication order written for Toradol with instructions not to give the med until 10pm. Instructions not read by nurse. Patient received Toradol against instructions. Two incidences

9. Medication Errors Patient ordered for Fentanyl 0 – 100 mcg / hour continuous infusion. Flow sheet indicated patient received 2.5 mL/hr = 25 mcg/hr. Pump programmed for 25 mL/hr = 250 mcg/hr. Patient bradycardic

10. Medication Error Bypassed verification of medication removed from Omnicell. Nurse intended to retrieve Haldol from Omnicell.

11. Medication Error Ommicell drawer contains both Haldol and Lasix. Removed Lasix from drawer. Administered wrong medication (Lasix) to patient IVP.

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