MEDICATION ERRORS AND RISK REDUCTION

1. Define medication error.

2. Identify factors that contribute to medication errors.
3. Explain the impact of medication errors on patients and health care agencies.
4. Describe methods for reporting and documenting medication errors.
5. Describe strategies that the nurse can implement to reduce medication errors
and incidents.
6. Explain how effective medication reconciliation can reduce medication errors.
7. Identify patient teaching information that can be used to reduce medication
errors and incidents.
8. Explain strategies used by health care organizations to reduce the number of
medication errors and incidents.
9. Identify governmental and national agencies that track medication errors and
incidents and provide information to health care providers

Medication Error

Is "any preventable event that may cause or lead to inappropriate medication

use or patient harm while the
medication is in the control of the health care professional, patient, or
consumer."
A medication error is any error that occurs in the medication administration
process whether or not it harms the patient. These errors may be related to
misinterpretations, miscalculations, misadministration, handwriting
misinterpretation, and misunderstanding of verbal or phone order

FACTORS CONTRIBUTING TO MEDICATION ERRORS

To be successful, proper medication administration involves a partnership

between the health care provider and the patient. This relationship is dependent
on the competence of the health care provider as well as the patient's full
adherence with the drug therapy regimen. This dual responsibility provides a
simple, though useful, way to conceptualize medication errors as resulting from
health care provider error or patient error. Clearly, the purpose of classifying and
studying these errors is not to assess individual blame but to prevent future
errors.

 Factors contributing to medication errors by health care providers

include, but are not limited to, the following:
 Omitting one of the rights of drug administration. Common errors include
giving an incorrect dose, not giving an ordered dose, and giving the
wrong drug.
  Failing to perform an agency system check. The pharmacist and nurse
must collaborate on checking the accuracy and appropriateness of drug
orders prior to administering drugs to a patient.
 Failing to account for patient variables such as age, body size, and
impairment in renal or hepatic function. The nurse should always review
recent laboratory data and other information in the patient's chart
before administering medications, especially for those drugs that have a
narrow margin of safety.
 Giving medications based on verbal orders or phone orders, which may
be misinterpreted or go undocumented. The nurse should remind the
prescriber that medication orders must be in writing before the drug can
be administered.
 Giving medications based on an incomplete order or an illegible order
when the nurse is unsure of the correct drug, dosage, or administration
method. Incomplete orders should be clarified with the prescriber before
the medication is administered. Written orders should avoid certain
abbreviations that are frequent sources of medication errors.
 Practicing under stressful work conditions. Studies have correlated an
increased number of errors with the stress level of nurses. Studies have
also indicated that the rate of medication errors may increase when
individual nurses are assigned to patients who are the most acutely ill.
Patients, or their home caregivers, may also contribute to medication errors
by:
 Taking drugs prescribed by several practitioners without informing each
of their health care providers about all prescribed medications.
 Getting their prescriptions filled at more than one pharmacy.
 Not filling or refilling their prescriptions.
 Taking medications incorrectly.
 Taking medications that may have been left over from a previous illness
or prescribed for something else.
II. IMPACT OF MEDICATION ERRORS

a. Medication errors are the most common cause of morbidity and

preventable death within hospitals.
b. When a medication error occurs, the repercussions can be emotionally
devastating for the nurse and extend beyond the particular nurse and
patient involved.
c. A medication error can lengthen the patient's stay in the hospital, which
increases costs and the time that a patient is separated from his or her
family.
d. The nurse or health care provider making the medication error may
suffer from self-doubt and embarrassment.
e. If a high error rate occurs within a particular unit, the nursing unit may
develop a poor reputation within the facility.
f. If frequent medication errors or serious errors are publicized, the
reputation of the facility may suffer, because it may be perceived as
unsafe. Administrative personnel may also be penalized because of
errors within their departments or the hospital as a whole.
g. There are no acceptable incidence rates for medication errors. The goal
of every health care organization should be to improve medication
administration systems to prevent harm to patients due to medication
errors.
h. All errors, whether or not they harm the patient, should be investigated
with the goal of identifying ways to improve the medication
administration process to prevent future errors.
i. The investigation should occur in a nonpunitive manner that will
encourage staff to report errors, thereby building a culture of safety
within an organization.
j. Analysis of error patterns can alert nurses and health care administrators
that a new policy or procedure needs to be implemented to reduce or
eliminate medication errors.

IV. REPORTING AND DOCUMENTING MEDICATION ERRORS

When a health care provider commits or observes an error, effects can be lasting
and widespread. Although some errors go unreported, it is always the nurse's
legal and ethical responsibility to report all occurrences. In severe cases, adverse
reactions caused by medication errors may require the initiation of lifesaving
interventions for the patient. After such an incident, the patient may require
follow-up supervision and medical treatments.
Reporting provides important and timely clinical information about safety issues
involving medical products, including prescription and over-the-counter (OTC)
drugs, biologics, medical and radiation-emitting devices, and special nutritional
products.

Encourage nurses and other health care providers to report medication errors
for its database, which is used to assist other professionals in avoiding similar
mistakes "to maximize the safe use of medications and to increase awareness of
medication errors through open communication, increased reporting and
promotion of medication error prevention strategies.

DOCUMENTING IN THE PATIENT'S MEDICAL RECORDS

All facilities should have clear policies and procedures that provide guidance on
reporting medication errors
Documentation of the error should occur in a factual manner; the nurse should
avoid blaming or making judgments Documentation does not simply record that
a medical error occurred. Documentation in the medical record must include
specific nursing interventions that were implemented following the error to
protect patient safety, such as monitoring vital signs and assessing the patient
for possible complications. Failure to report nursing actions implies either
negligence (ie., no interventions were taken) or lack of acknowledgment that the
incident occurred. The nurse should also document all individuals who were
notified of the error. The medication administration record (MAR) is another
source that should contain information about what medication was given or
omitted

Evidence: With the advent of the electronic health record system, previous
routines such as charting, prescribing and transcribing treatment orders, and
documentation have changed to electronic format. The submission of
medication orders previously handwritten by the health care provider is now
achieved by keyboarding the order into an electronic prescribing system. This
has the potential to dramatically cut down the risk for medication errors related
to unclear handwriting, misspelled drugs, incorrect dosages, and even
incompatible drugs because the electronic system has the ability to check and
cross-check for these errors. Although some of these benefits have been
realized, medication errors may still occur. Redwood, Rajakumar, Hodson, and
Coleman
(2011) studied the effect of electronic prescribing systems on the risk for
medication errors. Whereas the largest percentage of errors (85%) were related
to nonelectronic system problems such as errors related to dispensing of
incorrect drugs or incorrect administration, 15% of errors were related to the
electronic system itself.
Almost half of these errors (49%) were related to the failure of the person
administering the drug, most often the nurse, to include an electronic signature
after the dose was given. On further investigation, a few of these omissions were
related to the system itself, it did not retain the signature after it was put into
the system. Another third (31%) were related to technical-user issues, such as a
provider selecting an incorrect drug from a dropdown menu or duplicate orders
being placed for a "once-only" medication as well as ordering such medication
for routine use. The remaining percentages were errors related to lack of
adequate training on the use of the system by prescribers or users and errors
related to having mixed systems, with both paper and electronic records in place
at the same time, increasing the risk of duplication.

Nursing Implications: Electronic health records and electronic prescribing are

proving to reduce errors by providing up-to-the-minute information related to
the patient and the treatment plan. They are not without error, though, and the
nurse should be aware of the continuing potential for medication errors. When
using an electronic medication administration record, the nurse should assess
for the lack of documentation, which suggests a missing drug dosage, and, if
necessary, contact the nurse on the previous shift who cared for the patient to
verify whether the dose was given. Duplicate orders for one-time-only
medications and routine use of such medications should also be clarified with
the prescriber. Although electronic systems have the ability to reduce risk, they
are not completely error-free

REPORTING THE ERROR

In addition to documenting in the patient's medical record, the nurse making or

observing the medication error should complete a written report of the error.
Depending on the health care agency, these reports may be called "ncident
Reports," "Occurrence Reports," or similar titles. The specific details of the error
should be recorded in a factual and objective manner. The report allows the
nurse an opportunity to identify factors that contributed to the medication error
and assists in identifying any specific performance improvement strategies that
may need to be implemented The written report is not included in the patient's
medical record but is used by the agency's risk management personnel for
quality improvement and assurance and may be used by nursing administration
and education to identify common error occurrences and the need for
performance improvement or educational intervention Accurate documentation
in the medical record and in the error, report is essential for legal reasons. These
documents verify that the patient's safety was protected and serve as a tool to
improve medication administration processes.
Legal issues may worsen if there is an attempt to hide a mistake or delay
corrective action, or if the nurse forgets to document interventions in the
patient's chart.

V. STRATEGIES FOR REDUCING ERRORS

The most frequent types of drug errors vary depending on the specific
population (e.g., pediatrics versus geriatrics) or health care unit (e.g., intensive
care versus long-term care). The most common types of errors usually involve
administering an improper dose, giving the wrong drug, and using the wrong
route of administration. There is an increased risk for errors in the elderly
population because they often take numerous medications, have multiple health
care providers, and are experiencing normal age-related changes in physiology.
Children are another vulnerable population because they receive medication
dosages based on weight (which increases thepossibility of dosage
miscalculations), and the therapeutic dosages are much smaller.

What can the nurse do in the clinical setting to avoid medication errors and
promote safe administration?
The nurse can begin by following the steps of the nursing process:

Medication Reconciliation

Medication reconciliation is the process of keeping track of a patient's

medications as the patient proceeds from one health care provider to another.
Reconciliation accurately lists all medications a patient is taking in an attempt to
reduce duplication, omissions, dosing errors, or drug interactions. For example,
when a patient is admitted to care, the nurse records all medications the patient
has been taking at home, including the patient's dose, route and frequency. This
list is checked against admission orders and is transferred to other practitioners
whenever the patient is moved to a different unit within the hospital. It is also
checked at discharge. These "interfaces of care" are the most likely places that
medication reconciliation errors have been found to occur

Polypharmacy

Refers to patients to receive multiple prescriptions, sometimes for the same

condition, that have conflicting pharmacologic actions.

Note: Failure to properly record medication information, and to communicate

that information to health care providers, is a potential cause of medication
errors
Effective Patient Teaching for Medication Usage

An essential strategy for avoiding medication errors is to educate the patient by

providing written age-appropriate handouts, audiovisual teaching aids about the
medication, and contact information about whom to notify in the event of an
adverse reaction. The nurse should be attentive to the patient's ability to
understand the materials and to use any equipment such as medication cups
appropriately. Having the patient "teach back" to the nurse to confirm that the
patient has understood the content is a strategy that assists the nurse to
evaluate the teaching.

To minimize the potential for medication errors, the nurse should teach the
patients or home caregivers the following:

 Know the names of all medications they are taking, the uses, the doses,
and when and how they should be taken.
 Know what side effects need to be reported immediately.
 Read the label prior to each drug administration and use the medication
device that comes with liquid medications rather than household
measuring spoons.
 Carry a list of all medications, including OTC drugs, as well as herbal and
dietary supplements that are being taken. If possible, use one pharmacy
for all prescriptions.
 Ask questions. Health care providers want to be partners in maintaining
safe medication principle