The Practical Nurses Role in Preventing Medication Errors

1. The Practical Nurses Role in Preventing Medication Errors 8th EditionTextbook Chapter 9 Rev KBurger 0608

2. Medication Errors • 10 percent to18 percent of hospital injuries attributed to medication errors • 44,000 to 98,000 people die in U.S. hospitals annually due to medication errors

3. Medication Errors • Effects of medication errors • Increase length of stay • Increased cost • Patient disability • Death • Nurse’s personal and professional status, confidence, and practice

4. Nursing ResponsibilitiesLegal and Ethical • Nurses areliable for their actions, omissions, and for those duties they may delegate to others. • They are personally responsible…legally, morally and ethically…for every drug they administer.

5. Nursing Responsibilities • Obtaining current knowledge base of drugs • Referring to authoritative sources in professional literature (less than 5yrs old) • Questioning a drug order that is unclear or that appears to contain an error • Refusing to administer a drug if there is a reason to believe it will be harmful. • Performing correct techniques and precautions • Monitoring client response and documenting drug effects • Patient and family education

6. Nursing Responsibilitiescontinued • Know Information about the medicationAction – side effects – appropriate doseAge specific considerations – routes • Know Information about the clientWhat other medications are they takingALLERGIES or other problems w/ medsGag reflex – Impaired swallowingDietary and/or Fluid restrictionsCultural and/or religious influencesGenetic factorsVital signsLab values – renal & liver function / protein & albuminAge Pregnant/breast feeding

7. Nursing Responsibilitiescontinued • Using correct techniques of preparation and administration to deliver medications safely. • Monitoring the client for therapeutic and non-therapeutic effects of the drug • Client education for safe and accurate self-administration of the drug.

8. Legal Controls in Pharmacology Purpose and Scope of Legal Controls: • Protect public health and safety • Laws govern testing, production, distribution, prescription and the administration of drugs.

9. Federal Medication Laws

10. ***Controlled Substance Act • Designed to promote treatment and prevention of drug dependence • Established controls such as: -Prescribers are registered with the DEA. A registry number is issued to each person and is renewed annually. -Complete written records of all drugs prescribed must be kept for two years. Pharmacists record each sale in triplicate. Schedule II drug prescriptions cannot be renewed. -DEA (Drug Enforcement Agency) monitoring • Health care agencies must establish policies to comply with Federal law.

11. -All units have a record of every controlled drug on the unit and two nurses at the change of every shift count all drugs. -All controlled drugs are stored using a double lock system. Keys to medication areas are under the control of nurses on the unit. -Discarding of controlled substances must be witnessed by another nurse -Written renewal orders are required every 72 hours for narcotics and schedule II & III drugs. Controlled Substance Act - continued

12. Control Schedule Drugs with a significant potential for abuse are classified into 5 categories or schedules: Schedule I: highest potential for abuse Illicit drugs (Heroin, LSD, Marijuana) Schedule II: (Morphine, Dilaudid) Schedule III: (Vicodin, Meperidine) Schedule IV: (Valium, Xanax) Schedule V: lowest potential for abuse (OTC cough suppressant w/codeine)

13. Drug Information Resources • Agency pharmacists are an appropriate resource for obtaining drug information on the job. • Nursing drug handbooks: contain drug information along with nursing considerations. • Physician's Desk Reference (PDR) Contains manufacturer's descriptions (package inserts) which are written using FDA standards, but may be slanted in favor of the drug being described. • Package Inserts: Required by law for insertion with each new drug and must include a description, indications, precautions, dosage, and contraindications. • Electronic databases and Internet

14. Adverse Drug Events (ADE) • An undesirable occurrence related to administration of or failure to administer a prescribed medication. • General term that includes all types of clinical problems encountered regarding medications including:- adverse drug reactions (ADRs) adverse effects allergic reaction idiosyncratic reaction-medication errors (MEs)

15. Adverse Drug Reaction ADR • Any unexpected, undesired or excessive response to a medication given in therapeutic dosages) that results in:- temporary or serious harm or disability- admission to hospital, higher level care or prolonged stay- death

16. Adverse Drug Reaction continued • Adverse Effects:-Expected side effects (ie stomach upset)-Dose-related reactions (ie liver or renal impairement, geriatric and/or pediatric considerations)-Drug/Drug or Drug/Food interactions (ie potentiation of drugs by another drug, or drug not absorbed well with food)

17. Adverse Drug Reaction continued • Allergic Reaction:-Hypersensitivity ( ie: rash, anaphylaxis) • Idiosyncratic Reaction:-abnormal and unpredicted response specific to an individual (ie: confusion and antibiotics)

18. Nursing Measures to Prevent Medication Errors Order interpretation, reconciliation, and confirmation • Never assume anything about a drug order. CLARIFY, CLARIFY, CLARIFY • Make sure medication orders contain all (7) parts • Minimize use of verbal or telephone orders. If used, spell all drug names and repeat to confirm ( NOT LPN Scope) • Check Medication Administration Records (MAR)to the original prescriber order as per agency protocol.

19. Nursing Measures to Prevent Medication ErrorsSafe Medication Administration • USE THE SIX RIGHTS • Right drug • Right route • Right patient • Right dose • Right time • Right documentation

20. Right Patient • Correctly identify patient prior to medication administration using at least (2) identifiers. • Compare medical record number (MRN) on client armband with medication administration record (MAR) • Ask the patient to state his name & DOB • Compare picture to patient if available • Technological advances to prevent errorsBar-coding

21. Right Patient • Tell patient at time of administration what medication and dosage is being administered. Briefly explain therapeutic use of each medication • Patient may question drug or dosage • Re-confirm the drug order in chart and MAR • Provides an opportunity to do medication teaching

22. Right DrugThe (3) Checks • Check medication label 3X • On first contact with drug; when removing from medication box • Prior to measuring • Pouring, counting, or withdrawing • Just prior to administration; when returning to medication box

23. Right Drug • Be aware of distractions • Do not multitask during drug administration • Use bar-coding scanning when available • Be knowledgeable about the drug’s actions, indications, and contraindications • Be extremely vigilant about knownHIGH ALERT MEDICATIONS • Be alert to Look-a-like , Sound-a-like medications • Do not accept Drug Name Abbreviations(IE MS for Morphine Sulfate )

24. ISMP List of High-Alert MedicationsHYPERLINK Top (5) drugs involved in harmful errorsPINCHPotassiumInsulinNarcotics CoumadinHeparin ISMP List of Confused Drug NamesHYPERLINK Example:Tegretol versus Toradol(anticonvulsant versus antiinflammatory)Paxil versus Plavix(antidepressive versus antiplatelet) Use TALL-MAN letters Know both generic and trade names of drugs HIGH ALERT MEDICATIONSSound-a-like Look-a-like DRUGS

25. Right Route • Consult a drug information source to confirm correct route • Do not accept incorrect abbreviations:sq or sc – WHAT IS PREFERRED?JCAHO Do not Use List • Example: Be careful of:IVP versus IVPB

26. Right Route • May need to change or clarify forms or routes of the drug for safe medication administration • NPO status • Client inability to swallow pills • Nasogastric or surgically inserted tubes • Time-released or enteric-coated medications

27. Right Time • Order should include frequency of administration • Administer medications within 1 hr of prescribed time ( or per facility guidelines) • Use safe abbreviationsDo not accept: QD or QODWHAT IS PREFERRED???

28. Right Dose • Carefully read and clarify drug orders • Do not accept illegible handwriting • Do not accept leading or trailing zeroes • Do not accept U or IUWHAT IS PREFERRED? • Recheck labels 3 times!

29. Right Dose • Have two nurses double-check high alert medications • Consult drug references • Consider developmental age of client • Accurate dosage calculations

30. Right Documentation • Document IMMEDIATELY after administrationNEVER DOCUMENT BEFORE!!! • Omitting documentation can result in over or undermedication

31. Ethical Considerations • Respect of patient rights • Vigilant patient advocacy • Maintenance of knowledge and skills • Dedication to improvements in practice • Notification of patients regarding errors • Whistle-blowing

32. Genetic Factors • Age-related Factors: Pediatric- -absorption, distribution, metabolism, excretion differences - weight based dosingGeriatric- decreased body fat, lean muscle, water - decreased plasma proteins - diminished GI motility and absorption - slower liver and kidney function • Inherited Factors: • Slow versus Fast Acetylatorsdifferences in metabolism of drugs(IE: Asian Americans need lower doses of the antiaxiety drug Haldol) • Known Genetic group differences(IE: African Americans respond better to CCB drugs for hypertension)

33. Cultural Considerations • Varying health beliefs and practices • Folk and/or home remedies • Religious practices • Dietary practices • RESPECT for client’s cultural context