Zero Medication Error
By:
Edna Grace C. Ferrer, RN, MAN
Terms
Adverse Drug Reaction
- Unintended response to a medicine
that occurs at normal therapeutic
doses
Side-Effect
- Unintended effect of a drug
occurring at normal therapeutic
doses.
- Such effect may be well-known and
even expected
Terms
Serious Adverse Effect
- Untoward medical occurrence that
occurs at any dose that may cause
death or significant disability
Medication Error
- Broadly defined as error in
prescribing, dispensing, and
administration whether such errors
lead to adverse consequences or not
Sources of Medication Error
Inaccurate recording and transcribing
orders.
Unclear or erroneous labeling of drugs
Misidentification of client
Incomplete delivery of drugs
Verification errors
Use of inadequate or inaccurate
knowledge
Time and performance pressure
Common Medication Errors
Committed:
Medicine prescribed but not
given
Medicine given but not
prescribed
Medicine given to wrong
patient
Wrong medicine of IV fluid
administered
Wrong dose
Is it Preventable?
A medication error is a
preventable event that
may cause or lead to
inappropriate
medication use or
client harm while the
medication is in control
of health care
professional
Classifications
According to mistakes, slips,
or lapses
According to where they
occur in the medicating
process
Medicating Process
Prescribing
Transcribing
Dispensing
Administering
Monitoring
Classification according to
mistakes, slips or lapses
Prescribing Errors
Contributing Factors to
Prescribing Errors:
Lack of knowledge of the prescribed
drug, its recommended dose, and of
the patient details
Illegible handwriting
Contributing Factors to
Prescribing Errors:
Inaccurate medication history taking
Confusion with the drug name
Inappropriate use of decimal points
Use of abbreviations
Verbal orders
Risk Factors to Prescribing
Errors:
Work Environment
Workload
Communication within the Team
Physical and Mental Well-Being
Lack of Knowledge
Organizational factors such as
inadequate training
Low perceived importance of
prescribing
An absence of self-awareness of errors
Approaches to Reduce
Prescribing Errors:
Electronic
Prescribing
Computerized
physician order
Dispensing Error:
Occurs from the receipt of prescription
in the pharmacy to the supply of a
dispensed medicine to the patient
Primarily occurs with drugs with
similar name or appearance
Example: Lasix (Furosemide) and
Losec (Omprazole)
Potentially, could also include wrong
dose, wrong drug, or wrong patient
Approaches to Reduce
Dispensing Errors:
Ensure safe dispensing procedure
Separate drugs with similar name or
appearance
Avoid interruptions
Awareness of high-risk drugs
Introducing safe systematic
procedures for dispensing medicines
in the pharmacy
Administration Errors:
Occurs between the drug
received by the patient and the
drug therapy intended by the
prescriber
Errors of Omission – drug not
administered
Incorrect administration
technique
Expired preparations
Violation of guidelines
Causes of Administration
Errors:
Lack of perceived
risk
Poor role models
Lack of available
technology
Lack of knowledge
of the preparation
Complex design of
administration
equipment
Contributing Factors to
Administration Errors:
Approaches to Reduce
Administration Errors:
Checking patient’s identity
Double check dosage calculations
Ensure that the prescription, drug,
and patient are in the same place
Ensure the medication is given at the
correct time
Minimize interruptions drug rounds
Dosing Errors in Children
Lack of standard dosage
Individual dosage based on age,
weight or body surface area that
require calculations – prone to error
Failure to correctly estimate a child’s
weight
Scenario:
Jose Martinez was a two (2) month old
who exhibited early signs of CHF. His
physician ordered IV Digoxin over an
extended length of stay
Due to a decimal point error, Jose
received a dose that was ten (10)
times on what was intended. Jose died.
- Use of leading 0 and trailing 0.
“The order was suppose to be written
with a leading 0 – 0.5mg Digoxin”
Actions to be taken when
errors occur:
Client safety becomes the top
priority
Assess and examines the client’s
condition and notify physician of the
incident ASAP
Once the client is stable, a report
should be made to the appropriate
person – nurse manager or
supervisor
An incident report should be filed
Prevention of Medication
Error to Occur:
Follow the 14 Rights of Medication
Administration
Be sure to read labels at least 3 times –
before, during, and after administration
Check expiration date before
administration
Beware of ambiguous orders or drug
names – clarify to physician of in doubt
Double check calculations – even simple
calculations
Prevention of Medication
Error to Occur:
Do not allow interruptions during
preparation and administration
Do not use any not standard
abbreviations
Prevention of Medication
Error to Occur:
Read the drug literature if
administering for the first time or
unusual drug
Do not make assumptions
Do not accept incomplete orders
Double check with a client who has
allergies about all drugs added in the
treatment plan
Prevention of Medication
Error to Occur:
Check patient’s identification
properly BEFORE administration
Document all medication as soon as
they are given
When repeated medication error
occurs within the work area, identify
and analyze the factors that may
have caused errors and take
corrective action
Prevention of Medication
Error to Occur:
Introduce a “punishment free”
system to collect and record
information about medication-related
errors
Establish consensus group of
physicians, nurses, and pharmacists
to select best practices
Come to think of it….
You have given Mrs. Veena her
medication including cough Elixir. She
asks you, “you didn’t give me any
Codeine, did you? I am allergic to it.”
Then you reply, that there is no
Codeine in her medications
Returning to the medication room, you
think again and recheck. You found out
that the Elixir contains Codeine.
