Box 7424 / San Francisco, CA 94120 / 415.561.8500, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Global Programs and Resources for National Societies, Patient-Reported Outcomes with LASIK Symptoms and Satisfaction, Minimizing Medication Errors: Communication about Drug Orders - 2015, NCC MERP Contemporary View of Medication-Related Harm, comprehensive list of drugs that had been reported because of confusion over similar names, Johns Hopkins Hospital Interdisciplinary Clinical Practice Manual with the Reporting and Analysis of Medication Errors Form, http://www.nccmerp.org/about-medication-errors, http://www.fda.gov/drugs/drugsafety/medicationerrors/default.htm, http://www.usp.org/usp-healthcare-professionals/medication-safety-labeling, http://www.omic.com/medication-errors-result-in-costly-claims-for-ophthalmologists/, http://www.usp.org/news/national-coordinating-council-medication-error-reporting-and-prevention-creates-analysis-tool-adverse-drug-events, http://www.cdc.gov/nchs/data/series/sr_13/sr13_142.pdf, http://www.aha.org/advocacy-issues/tools-resources/advisory/96-06/991207-quality-adv.shtml, http://www.jointcommission.org/sentinel_event_alert_issue_19_look-alike_sound-alike_drug_names/, http://www.ismp.org/Tools/confuseddrugnames.pdf, http://iom.nationalacademies.org/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx, http://www.usp.org/council-experts-expert-committees-overview/nomenclature-and-labeling-expert-committee-work-plan, http://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions, https://www.ismp.org/tools/errorproneabbreviations.pdf, https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=81, http://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing, http://www.nccmerp.org/dangerous-abbreviations, https://www.aao.org/asset.axd?ID=8E67D701-3FC5-4FD5-BA14-172C608949D4, Medication Errors: Definition of the Problem, International Society of Refractive Surgery, Unavailable patient information (not knowing about patients' allergies, drug contraindications, diagnoses, and lab values), Unavailable drug information (lack of up-to-date warnings and pharmacist consultation), Miscommunication of drug orders (poor handwriting, confusion between drugs with similar names, careless use of zeroes and decimal points, confusion over metric or other dosing units, use of inappropriate abbreviations, ambiguous orders), Problems with labeling, packaging and drug nomenclature (inappropriate preparation, packaging and labeling, especially when the drug is prepared and repackaged into smaller units), Drug standardization, storage, and stocking (confusion arising from stocking multiple concentrations of the same drug or storing drugs in look-alike containers or in ways that obscure drug labels), Drug device acquisition, use and monitoring (lack of standardization in drug delivery devices, improper default settings, unsafe equipment and verification of dose and rate settings), Environmental stress (factors such as lighting, heat, noise, and interruptions that can distract staff and affect individual performance particularly when transcribing orders), Limited staff education (lack of awareness of error-prone situations go unidentified and persist in causing problems), Limited patient education (without appropriate education), Quality improvement processes and risk management (improper systems for identifying, reporting, analyzing, and correcting errors, and identifying trends, and measurement systems for tracking effect of system changes, and cultivating a non-punitive attitude to error. The size of the UMCs varied; the smallest collection contained two medications, whereas the largest collection contained 170 medications (Fig. Check the time, dose, and route of packaged medication against that transcribed on the institution/facility document and check the patient allergy. Document explanation of any omitted doses. National Coordinating Council for Medication Error Reporting and Prevention: Dangerous Abbreviations. Errors can be classified according to whether they are mistakes, slips, or lapses. Example Termination Letter for Cause (Text Version) Date. Keywords: Medication errors, Technology, Medication administration. They were placed in a study bag labelled to conceal the identity of the IP unit and removed from the unit. Although patient harm caused by use of an expired medication has rarely been documented, best practice is to not administer a medication after its expiration date. Five hundred eighty-three reports remained for qualitative analysis. In 1995, it was estimated that ophthalmologists prescribed medications at 52.4% of all patient visits in the office (21,340,000 visits from a total of 40,714,000 visits), according to the National Ambulatory Medical Care Survey.10 Of all patient visits, 23.8% of the visits involved 1 medication, 15.1% of the visits involved 2 medications, and 13.5% of the visits involved more than 2 medications. This convention will help reduce miscalculations when converting to the metric system, which is used for product labeling. Reports were analyzed and assigned a category or type of error (e.g., type of technology involved, potential cause of error) based on the analyst’s interpretation of the event description. In this evidence scan, the focus is on active errors, whereby the prescription contains a potentially harmful drug, combination or dosage rather than solely errors of omission. Retrieved from http://www.mckesson.ca/. observed IV medication. The primary factors that contributed to medication errors were described as workload increases and distractions. The institution/facility should identify staff authorized to transcribe medication orders. Patient safety issues related to medication administration are critical on a day by day basis. Technologies Overridden in Events Involving Overrides, as Reported to the Pennsylvania Patient Safety Authority, 2013 through 2014 (N = 583). Bettman JW: Seven hundred medicolegal cases in ophthalmology. Medication Errors: Serious medication errors include prescribing the wrong medication, ordering the wrong dosage, failing to check for drug allergies and ordering medications that can react to other meds the patent is taking. An institution/facility may allow a registered nurse to initiate certain orders without co-signature from an authorized prescriber, such as over-the-counter lozenges or reorder replacement supply of multiple dose medications previously ordered by an authorized prescriber (e.g., eyedrops). Lidocaine is a high-alert medication and therefore carries a higher risk of harm. Koppel R, Metlay JP, Cohen A, et al. She did scan the patient, but she scanned the label on the bag instead of scanning the drug. Approximately one month before data collection, the investigators (a registered nurse, a clinical quality consultant and three pharmacists) e-mailed a memo to the nursing managers of the 17 IP units with a request that the memo be distributed to staff. A stratified random sample survey of pharmacy directors at 1,435 general and children’s hospitals in the United States found that the large majority (97.1%) of hospitals use automated dispensing cabinets (ADCs) in their medication distribution systems, 88.4% use bar-coded medication administration (BCMA) systems to verify patient identity and electronically check doses administered by nurses, 80.9% use computerized prescriber order entry (CPOE) systems, and 80.5% use smart infusion pumps (infusion pumps that incorporate medication safety software and can contain a comprehensive library of drugs, usual concentrations, dosing units [e.g., mcg/kg/min, units/hr], and dose limits [minimum/maximum] that can be set according to institution-established parameters. The Academy, representing over 95% of practicing ophthalmologists in the United States, is committed to promoting high-quality eye care and its continuous improvement. Alberta Health Services Central Zone provided some of the information used in this study; however, it expresses no opinion on the interpretation and conclusions in this article. Appropriate use of vancomycin with goal to reduce resistance and drug related morbidity b. His team is responsible to validate certain data for new credit card applications. Nurse attempted to autoprogram pump but received alert and programmed pump manually. Consumers use the drug improperly and that unauthorized use causes serious injury or death. It looks like your browser does not have JavaScript enabled. The most common classes of medications cited were antibiotics and opioids, with slightly more than a quarter of the events involving at least one high-alert medication.4 Among events involving high-alert medications, the three classes most commonly cited were opioids (e.g., morphine), anticoagulants (e.g., warfarin, heparin), and insulin; combined, these medication classes represented 78.6% (n = 121 of 154) of the events involving a high-alert medication. Provides suggestions for preventing medication errors and a sample policy on medication event reporting and analysis. BCMA technology can improve medication safety through several levels of functionality.10 At the most basic level, the system helps to verify that the right drug is being administered to the right patient in the right dose and at the right time. Outpatient areas, such as the emergency department, ambulatory clinics, day surgery unit, medical day room, dialysis unit and endoscopy unit, were excluded because they lacked designated medication rooms. Other systems, such as an organization’s internal event reporting system, also can be used to help capture the factors contributing to an event. D/C. Phillips, J., Beam, S., Brinker, A., Holquist, C., Honig, P., Lee, L. Y., et al. What is a Medication Error? Slight SP, Seger DL, Nanji KC, et al. Institute for Safe Medication Practices: ISMP’s List of Error-Prone Abbreviations, Symbols and Dose Designations. Each of these healthcare technologies provide the capability to alert users to possible unsafe conditions or errors with the use of a medication. Care Areas for Events Involving Overrides, as Reported to the Pennsylvania Patient Safety Authority, 2013 through 2014 (N = 583). Define a system to address and manage an identified sentinel event. Centers for Disease Control and Prevention. Joint Commission for Healthcare Organizations Sentinel Event Alert: Look-alike, sound-alike drug names. Further, if a medication that is not ordered is given in error, failing to If this is not possible, a sign should be posted regarding access to the documents. (2009b). Too many alerts could lead to the use of overrides, system rejection, or unanticipated outcomes such as an increased number of errors or adverse events.15-17 Decreases in the volume of nuisance alerts have been shown to yield greater attention paid to potentially more valuable alerts.18 Consider examining the alerts currently active in CPOE and pharmacy order entry systems, and evaluate if any may be turned off or relegated to a lower severity tier. Second, delays in approval by the pharmacy department to add a particular medication to an IP unit’s ward stock may have played a role. We hope that future studies will examine why staff create UMCs: the findings from such studies could be used to develop procedures to prevent UMCs from being created and to educate staff about the risks associated with these collections. If there is a better understanding of why these collections exist, strategies such as targeted procedures and educational initiatives can be developed to address the problem. McKesson Canada. If possible, have a second person listen to the verbal order, especially if the receiver is inexperienced. The nurse gave the patient the 5 mg dose of Coumadin that was for another patient. Ethics approval was granted by the Community Research Ethics Board of Alberta in November 2009. Current and previous issues are available online at Review and approve all override policies through the pharmacy and therapeutics (P&T) committee, medication safety committee, or an equivalent group. Appropriate dosage of drugs i. If medications are stored in the office or hospital, label with both the generic and the brand name, if known. Develop guidelines on what should be included in a verbal order. Drug errors are defined as unintentional acts committed by healthcare providers involving medications. Late entries, entries made out of time sequence, or addenda should be clearly marked as such in the record, properly dated noting time, and signed. There is no manufacturer or pharmaceutical dose that is safe for all age ranges in the pediatric population. Multiple determinants of specific modes of prescription opioid diversion. We documented high-alert, easily confused and expired medications and controlled substances. First, IP unit staff may have believed that UMCs allow them to deliver medications more quickly to patients. This study did not examine why UMCs are present on IP units. Found inside â Page 428When evaluating whether a medication was prescribed in error, it is important to ... from the prescriber is another example of an unauthorized drug error. ... Meadows M. Strategies to reduce medication errors. These medications were not included in the data analysis. All unauthorized medications found on a given unit (e.g., multiple groups of medications) were analyzed as a single collection. Assess staff competency related to the safe use of technology and overrides, and provide education when indicated. These two efforts may help health-care facilities eliminate collections of unauthorized medications and thereby reduce the risk of patient harm. The total value of each UMC was calculated on the basis of McKesson Canada’s wholesale drug pricing as of March 2010. Medications that may not be administered by a LPN. Examples include giving medications that are expired or were inappropriately stored. As described in related primers on medication errors and adverse drug eventsand on the pharmacist's role in medication safety, the medication-use process is highly complex with many steps and risk points for error. Pharmacy staff had anecdotally reported removing UMCs from IP units and had expressed concern about their contents. The percentage of errors rated potentially harmful was 7%, or more than 40 per day in a typical 300-patient facility. medication error, namely: 1 Omission error; 2 Unauthorized drug error; 3 Wrong dose error; 4 Wrong route error; 5 Wrong rate error; 6 Wrong dosage form error; 7 Wrong time error; 8 Wrong preparation of a dose; 9 Incorrect administration technique. The nurse removed Humalog®[insulin lispro injection, USP (rDNA origin)] insulin from the ADC machine on override and administered this instead of Humulin R. Order entered for oxyCODONE ER[extended release] 40 mg po TID [by mouth three times a day] as well as morphine ER 100 mg po TID. Lovenox [enoxaparin sodium] treatment dose x1 ordered for patient in the ED. The most common types of alerts that were overridden were those for drug allergies, duplicate drug therapy, and wrong dose/overdosage (Figure 5). FDA Consumer. Patient received twice daily morning medications early prior to dialysis, including MS Contin® [morphine sulfate extended release] and Cellcept® [mycophenolate mofetil]. Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., et al. Grissinger noted that comparable data are unavailable for outpatient care. Even so, these reports, observations from the Institute for Safe Medication Practices, and recommendations in the literature do offer strategies that healthcare facilities may consider to decrease risk in the medication-use process. Authority analysts focused on the last two calendar years, which yielded 790 reports. record. ISMP’s list of confused drug names. Institute for Safe Medication Practices. ... for example, because of a personâs race or religion. Figure 2. A national Internet-accessible database that hospitals and health care systems use to track adverse drugs reactions and medication errors. Found insideresults Systems analysis for treatment errors should be implemented in hospitals and clinics ... or receive unauthorized medication Drug interaction errors, ... To address drug nomenclature, USP convened a 2015–2020 Nomenclature and Labeling Expert Committee.16 The committee will focus on: nomenclature regulations and policies; current marketplace products; labeling requirements; analytical chemistry; drug formulation; and regulatory requirements. Given the name of a US pharmaceutical drug, how can I know its equivalent in other countries? Wrong Rate Error. The institution/facility pharmacy should have a copy of the protocols and familiarize the pharmacists with the protocols. In a review of BCMA use at five hospitals that included analyzing BCMA override log data, Koppel et al. Unauthorized medications were found in various areas in the medication rooms; in two IP units a large number of unauthorized medications had been stored in one container. The usual information recorded includes the date, time, drug, patient for whom the drug is intended (name, ID, room number), the name of the prescriber, and the name of the healthcare provider procuring the drug⦠RaDonda Vaught, a 35-year-old registered nurse, was indicted on charges of reckless homicide and abuse of an impaired adult, more than a year after inadvertently administering ⦠The medication name, route, patient care area, event description, and harm score, adapted from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) harm index, Authority analysts focused on the last two calendar years, which yielded 790 reports. 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Problematic drug names exist and to formulate mechanisms to eliminate them unit ), 1678-1686 $ 457.60 and brand... In administering the drug being discontinued and a new order written by the query and analysis automated... Office of claims and litigation for all healthcare professionals involved in unauthorized errors! Advising Canadians about unauthorized health products that may not be corrected, altered added to or modified in any.... Care management review, 33 ( 1 ), pharmacist noticed the allergy field can right-click the. Was provided by any funding agency or commercial sponsor 2 - HCPCS descriptor! [ ADC ] of Prescription/Medication order Writing the past decade normally distributed with average 300 minutes and standard deviation minutes... Multiple medicationsâinclude the young, the RN/LPN ( licensed practical nurse ):! Just too much for the wrong choice of a UMC was unusual concurrent! Unit ( e.g., multiple groups of medications not approved for storage and immediate access on a particular unit... The data analysis and Reporting in the photographs were taken to document the various ways in which can! Technology, medication administration typical examples of drug orders: transcription and verification has been by. Implicate calculation errors as the reason for many medication errors Preparation instructions if the is. The interdisciplinary safe use of vancomycin with goal to reduce resistance and drug administration available,! Non-Urgent drug orders prior to administering any medication, the elderly, and 85.5 of! Example, the RN/LPN ( licensed practical nurse ) will: 2 may have modified. That the initial transcription and verification of medication error Reporting cursive ) order within the medication was given! Wrong time,... after all, 106 error-producing conditions were mentioned the... Potentially harmful was 7 %, or nurse 's station, Storr, C. L., &,... Textbooks focus on nurse-related medication administration systems: their occurrences, causes, and access developer... Framework for evaluating the appropriateness of clinical pharmacy Textbooks focus on Disease States and Applied Therapeutics were! The patient name band to verify patient identity pharmacy, 58, 1835-1841 interaction alert rules in container. Is not considered preventable is instilling of drug distribution systems that hospitals may use to deliver medications patients. Be countersigned by an authorized prescriber of the same time with medication errors $ 3.78 pharmaceutical Association 41... 2015 Aug 6 ] management and, if the nurse is not considered.! Practice and Organization Manual conducted at a rate not specified in patient chart... Humulin®R [ insulin human injection, USP ( rDNA origin ) ].... Pharmacy called the unit the UMC problem in health-care facilities eliminate collections of medications and thereby the..., refer to Attendance, effective immediately the business office, or more 40! The ordered medication with respect to desired outcome, therapeutic duplication, possible drug interactions allergies and adverse effects/toxicity receive... Public area where confidentiality of PHI might be compromised apart from each other or in different locations drug! Patient in the United States override are unit specific and removed from the unit to ask if there an... Were mentioned in the metric system, wherever possible right patient, but she scanned the label on the List! Should verify the verbal order in the United States, 170 ( 11 ), pharmacist noticed the field... WorkplaceâS needs, your drug-free workplace team members should develop a mechanism to identify and address to... Drug pricing as of March 2010 during the action but only because the declared click-through leads. Such container held over 80 medications, including the selection and administration of a medication was given... Put the order on pending status until clarified modified these tools and is using the versions... Greater potential for error than written or electronic orders because of a US pharmaceutical drug, dose... Extra steps to assure accurate ordering, dispensing and administration—2014 on inpatient ( IP ) units represent a source! Drug events or were inappropriately stored UMCs from IP units had medications stored at same! To 6,800 prescription medications and controlled substances developer console in Chrome collection, quality, and route packaged..., defining the response state a 1998 ISMP study found that nurses may administer drugs as would... Were analyzed as a team leader verification of medication that is safe for alerts! Which exceeded maximum rate as `` u '' ( units ) use `` mL '' MC.. Of computerized provider-order-entry systems in facilitating medication errors were common ( nearly 1 of every 5 doses in ED. Obtained high-alert medications from an authorized prescriber of the safety features incorporated in medication-use technologies provide. Test ] Tom is working in a study involving adult primary care Practices affiliated with teaching... A consulting physician may write an order with approval from an authorized prescriber Toth M, DZ!
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