Medication Errors Workshop
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Medication Errors Workshop Presented by: APS Healthcare Southwestern PA Health Care Quality Unit (HCQU). December, 2009 sc,alt. Disclaimer.

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December, 2009 sc,alt

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December 2009 sc alt

Medication Errors WorkshopPresented by: APS HealthcareSouthwestern PA Health Care Quality Unit(HCQU)

December, 2009 sc,alt



Information or education provided by the HCQU is not intended to replace medical advice from the consumer’s personal care physician, existing facility policy or federal, state and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those who attend a training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.

Note of clarification

Note of Clarification

While mental retardation (MR) is still recognized as a clinical diagnosis, in an effort to support the work of self-advocates, the APS SW PA HCQU will be using the terms intellectual and/or developmental disability (I/DD) to replace mental retardation (MR) when feasible.



Upon completion of the session the participant will:

  • 1. Describe how a systems approach can help to prevent/reduce medication errors

  • 2. Utilize key system elements to identify contributing factors to medication errors

  • 3. Analyze a medication error using the root cause analysis method

Workshop plan

Workshop Plan

  • Brief review of medication errors

  • Group activities

    • Identification of medication errors

    • Typing of medication errors

    • Categorizing of medication errors

  • Performance of root cause analysis

Medication error defined

Medication Error Defined

  • Preventable event

  • May cause/lead to inappropriate medication use or individual harm

  • Medication in control of healthcare professional or consumer

    National Coordinating Council for Medication Error Reporting and Prevention

  • Violation of one of five rights

  • Incorrect medication procedure

    Office of Developmental Programs

Where errors occur

Where Errors Occur

Types of medication errors

Types of Medication Errors

  • Omission

  • Commission

Errors of commission

Wrong dose

Wrong time

Wrong person

Wrong medication

Discontinued medication

Extra dose

Wrong medication

Wrong route

Wrong position

Wrong technique or method

Wrong form

Errors of Commission

Principles of medication error reduction prevention

Principles of Medication Error Reduction & Prevention

  • Goal of every organization

  • Use of systems approach

  • Assess risk

    • Failure mode and effects analysis (FMEA)

  • Assess errors and near misses

    • Root cause analysis (RCA)

Key system elements

Key System Elements

  • Policies & procedures

  • Individual information

  • Medication information

  • Communication

  • Medication names

  • Labeling & packaging

  • Standardization, storage, & distribution

Key system elements1

Key System Elements

  • Delivery systems

  • Environment & staffing

  • Competency & education

  • Individual education

  • Monitoring

  • Documentation

  • Quality improvement & risk management

Policies procedures

Policies & Procedures

  • Basis for medication use system

  • Govern sub-processes

Individual information

Individual Information

  • Vital to physician, pharmacist, and staff

Medication information

Medication Information

  • Current

  • Readily available

  • Identification of High Alert Medications



B/W team members

Method used



Use of abbreviations, symbols, dose expressions


Medication names

Medication Names

  • Sound alike

  • Look alike

Labeling packaging

Labeling & Packaging

  • Similarities

  • Confusing

  • Mislabeling

Medication standardization storage distribution

Medication Standardization, Storage, & Distribution

  • Standards in place

  • Safe storage

  • Timely ordering and delivery

Medication delivery systems

Medication Delivery Systems

  • Syringes: Oral vs. Parenteral

  • Glucose monitors



  • Lighting

  • Noise

  • Temperature

  • Distractions

  • Interruptions

  • Unit organization



  • Physical health

  • Emotional health

  • Work schedule

  • Fatigue

  • Medications

  • Interpersonal relationships

  • Confirmation bias

Competency education

Competency & Education

  • Orientation

  • Certifications

  • Annual competencies

  • Skills labs

  • In-services

Program participant education

Program Participant Education

  • Knowledge of medications

  • Encouraged to ask questions



  • Adverse side effects/toxicity

  • Medication interactions

  • Diagnostic studies

  • Allergies



  • Standardized

  • Individual

Quality improvement risk management

Quality Improvement & Risk Management

  • Leadership

  • Non-punitive systems based approach

  • Error reporting

Benefits of systems based approach

Benefits of Systems Based Approach

  • Reduction of medication errors and near misses

  • Safer medication use system

  • Empowers staff

  • Morale improves

Group activities

Group Activities

  • Identification of medication errors

  • Typing of medication errors

  • Categorizing of medication errors

  • Performance of root cause analysis



Institute for Safe Medication Practices (2009). FAQ. Retrieved August 24, 2009 from , Web site:

Cardinal Health (2009). Statistics. Retrieved August 24, 2009 from , Web site:



Morrow, J., & Breen, B. (2004). PA DPW OMR: Training how to administer medications the right way.

National Coordinating Council for Medication Error Reporting and Prevention ( 2009). What is a medication error?. Retrieved August 24, 2009 from , Web site:



Folino, E. (2004). Medication errors: Preventing the preventable ppt.

National Coordinating Council for Medication Error Reporting and Prevention ( 2009). Council recommendations. RetrievedAugust 24, 2009 from , Web site:

Suggested supplemental training

Suggested Supplemental Training

  • Medication Administration

  • Preventing & Reducing Medication Errors

  • Aging: Medication Management

  • Medication Side Effects

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To register for future trainings,orfor more information on this or any other physical or behavioral health topic, please visit our website at

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EvaluationPlease take a few moments to complete the evaluation form found in the back of your packets.Thank You!

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Test ReviewThere will be a test review after all tests have beencompleted and turned in to the Instructor.

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