Medication Errors: An Interdisciplinary Approach

1. Medication Errors: An Interdisciplinary Approach

2. Roberta McIntyre, MSN, RN Nursing Service Consultant Office of Developmental Programs Western Region

3. Goals: • 1. Define medication error • 2. Identify types of medication errors • 3. Identify strategies to reduce medication errors

4. Definition: • Any wrongful or incorrect administration of a medication • Any preventable event that may lead to inappropriate medication use or patient harm • A failure in the treatment process that does or has the potential to lead to patient harm

5. Keys To Prevention: • Report all near misses and med errors • Turn drug administration into a protected time • Do not be afraid to question anything you suspect is not correct

6. The Five Rights • Right person • Right medication • Right dose • Right route • Right time

7. Three Goals of Medication Administration: • 1. Reduce or eliminate the possibility of an error • 2. Make errors visible before they reach the patient • 3. Minimize the consequence of an error if it does reach the patient

8. Abbreviations and Symbols

9. Quality Process and Risk Management • Make it difficult for staff to make an error • Promote detection and correct errors before reaching the patient and causing harm

10. Methods to Investigate Errors

11. Debriefing Process • 1. Approach Staff • 2. Ask staff • 3. Ask staff

12. Achieved Objectives • Agency intent • One on one time with staff • Uncover additional issues • Staff ownership

13. Debriefing Goals • 1. Prevent or minimize future occurrences • 2. Decrease the harm of future med errors • 3. Identify systemic problems • 4. Identify need for change

14. HCSIS Reporting System

15. Why Report Errors • Potential risks • Actual errors • Cause of errors • Prevention

16. What To Report • Risk • Near misses • Errors, no harm • Errors, harm

17. Informative Reports Include: • HOW • WHY • SUGGESTIONS

18. HCSIS System • WHY • WHAT • AGENCY RESPONSE

19. Any Questions?

21. Contact Information • Roberta McIntyre, MSN, RN Nursing Service Consultant ODP – Western Region 301 Fifth Avenue Suite 490 Piatt Place Pittsburgh, PA 15222 412-880-0594 rmcintyre@pa.gov