2. MEDICATION ERROR

3. PURPOSE / POLICY Purpose: To provide a process for identifying, reporting, and reviewing medication errors Policy: Any med error will be reported to the DON, ED and QA departments. The process will be collaborative among nursing, pharmacy and others as appropriate (patients physician must be notified)

4. DEFINITION OF MED ERROR Any error, which includes, but not limited to: Patient and/or family/caregiver does not follow physician’s orders or nurse instructions in administering meds WRONG MED, wrong time, wrong dose, wrong route of administration during intervention by the nurse, extra dose, omission of ordered drug MISSING a scheduled administration of SQ/IM/IV med for any reason

5. PROCEDURE If an error is made, the personnel making or discovering the error will notify DON, then physician The DON will be notified of the physician’s comments and correction to orders, if applicable The patient will be observed for any untoward effects of the med error for the duration of the excretion time (1/2 life of med) and notation of such made (documented in EMR) – if applicable 911 will be called (over sedated, obtunded) If appropriate, the pharmacist will be notified for any further actions that may be required

6. PROCEDURE If the error has been one of omission, the physician or DON will be requested to instruct the nurse as to a corrected med schedule The error will be noted in the EMR. Events and actions are OBJECTIVELY outlined in the clinical notes An incident report will be completed by nurse making error, the nurse who discovered error, and/or DON All medication errors/incident reports will be reviewed by the QA nurse