Safe Medication Administration

1
Safe Medication Administration
TOGETHER, WE CAN MAKE THE ORDINARY EXTRAORDINARY

• Ohio Regional Clinical Competency
• Adapted for use by Nursing Administration

2
Learning Objectives

• After completing this competency presentation,
  the nurse should be able to
• List the five most common reasons for medication
  errors.
• Discuss strategies that can be incorporated into
  practice to reduce the potential for making these
  errors.
• Have knowledge of the regional program, policy
  and procedures related to the handling of high
  alert medications.
• List the six rights nurses have when it comes to
  administering medications.

2
3
Preventing Medication Errors

• It may seem a strange principle to enunciate as
  the very first requirement in a Hospital that it
  should do the sick no harm
• 
  -----Florence
  Nightingale, 1859
• The goal of every healthcare organization should
  be to continually improve systems to prevent
  harm to patients due to medication errors
• 
  -----The Institute for Safe Medication
  Practices, 2011

3
4
Competency Content

• During the course of this competency you will
  read scenarios of actual medication errors that
  have occurred in regions and were reported.
• All specific information related to persons or
  locations involved in these reported incidents
  has been removed. Only the name of the drug and
  the explanation of the error are included. These
  incidents have been incorporated into this
  competency for educational purposes only and not
  to highlight any one incident. Inclusion of a
  particular scenario should not be interpreted as
  a reprimand.
• We sincerely thank the nurses who took the time
  to file these incidents and we encourage more
  reporting of medication errors or near misses as
  this helps us to identify potential problem areas
  and improve our safety systems utilizing the Ohio
  Regions PEMENIC reporting system
• We are all human, and we all make mistakes at one
  time or another, however errors in medication
  administration affect the patients that we care
  for and we should make every effort to avoid
  them. The purpose of this competency is to
  discuss strategies to help prevent errors and to
  encourage KPOH clinical staffs to slow down and
  take the time necessary to administer medications
  safely. Medication administration is one of the
  most important and serious things that we do
  every day as nurses and we must make sure that we
  do it as responsibly as possible.

4
5
Reasons Medication Errors Occur

• There are many factors that contribute to nurses
  making medication errors.
• The top five most commonly reported reasons that
  nurses make medication errors in our region are
• Failure to follow the Five Rights of medication
  administration
• Communication issues
• Knowledge deficit
• Distractions during preparation and
  administration
• Confusion of Look Alike/Sound Alike medications
• Lets take a look at each of these areas
  individually and review strategies you can use to
  prevent each one from interfering with your
  ability to safely administer medications to your
  patients.

5
6
Medication ErrorsFailure to Follow the Five
Rights

• First, lets review the Five Rights of Medication
  Administration
• As nurses it is our responsibility to give the
• RIGHT DRUG
• in the
• RIGHT DOSE
• to the
• RIGHT PATIENT
• by the
• RIGHT ROUTE
• at the
• RIGHT TIME
• Although it may seem simple, failure to follow
  one or more aspects of the Five Rights is the
  number one reported nursing medication error in
  our region!

7
Medication ErrorsFailure to Follow the Five
Rights

• Right Drug
• Scenario
• A pediatrician ordered an MMR vaccine for a
  patient during the course of a routine office
  visit.
• The nurse inadvertently administered a varicella
  vaccine to the child instead of the MMR.
• Taking the time to check and cross-check the
  providers order with the medication selected and
  prepared could have prevented this administration
  error.

8
Medication ErrorsFailure to Follow the Five
Rights

• Right Drug
• Here are some strategies you should use to ensure
  that you are administering the right medications
  to your patient.
• Check the provider order and medication label
  three times, comparing the two, before
  administering.
• Know the reason why the drug is being given to
  the patient.
• Avoid pre-pouring medications or preparing them
  ahead of time. If you must do this make sure that
  you label the prepared drug as follows
• Name of Drug Date Time Prepared
• Time of expiration Your name or initials
• Do not administer medications prepared by someone
  else.
• Do not administer medications if the label on the
  drug container is unclear or unreadable.
• Make sure medications are stored correctly and
  clearly labeled.

9
Medication ErrorsFailure to Follow the Five
Rights

• Right Dose
• Scenario
• A physician in a busy clinic that treats adult
  patients ordered a dose of Procrit 4,000 units
  subcutaneously for a patient.
• The nurse inadvertently administered 40,000 units
  subcutaneously.
• Taking the time necessary to do careful and
  accurate dosage calculations and possibly
  verifying those calculations with another nurse
  could have prevented this error from occurring.

10
Medication ErrorsFailure to Follow the Five
Rights

• Right Dose
• Here are some strategies you should use to ensure
  that you are administering the correct dose of
  medications to your patient
• Check the provider order and medication label
  three times before administering.
• Do thorough calculations to determine dosages,
  use a calculator.
• Ask another nurse to double check your
  calculations.
• Know the appropriate dosage range for the drug
  you are administering.
• Use only approved abbreviations, and double check
  to make sure all abbreviations are clearly
  understood.
• Make sure medications are stored appropriately
  and different doses are physically separated.

11
Medication ErrorsFailure to Follow the Five
Rights

• Right Patient
• Scenario
• In a busy specialty department that sees
  pediatric patients, a physician ordered a
  medication for a child prior to a procedure. In
  preparation for the procedure a Clinical
  Assistant moved the patient from the exam room
  into another room within the department. A second
  child was then placed into the exam room.
• A busy nurse, knowing only that the patient in
  room 4 was to get a medication, prepared the
  drug, entered the room and administered it to the
  child in the room without verifying that childs
  identity.
• The medication was given in error as it was
  intended as a pre-procedure drug for the first
  child.
• Simply taking the time to verify the childs
  identity prior to administration could have
  prevented this error from occurring.

12
Medication ErrorsFailure to Follow the Five
Rights

• Right Patient
• Here are some strategies you should use to ensure
  that you are administering medications to the
  right patient.
• Check two identifiers-full name and date of
  birth-on every patient, every time medication is
  administered.
• Do NOT use room numbers or health conditions to
  identify patients (the patient in exam room 6
  needs ibuprofen or the lower back pain needs a
  Toradol injection)

13
Medication ErrorsFailure to Follow the Five
Rights

• Right Route
• Scenario
• A physician ordered a dose of Phenergan 25 mg
  intramuscularly for a patient during the course
  of an office visit.
• The nurse inadvertently administered Phenergan 25
  mg intravenously to the patient.
• Taking the time to check and cross check the
  order to ensure complete understanding could have
  prevented this error.

14
Medication ErrorsFailure to Follow the Five
Rights

• Right Route
• Here are some strategies you should use to ensure
  that you are administering medications by the
  correct route to your patient
• Check the provider order and the medication label
  three times before administering.
• Know the recommended routes of administration for
  the drug you are giving.
• Know the specific administration techniques for
  drugs you are giving (subcutaneous, intravenous
  by slow or rapid infusion etc.)

15
Medication ErrorsFailure to Follow the Five
Rights

• Right Time
• Scenario
• A patient presented to a busy clinic that treats
  adults requesting a travel shot. The nurse
  reviewed the notes in the chart in order to
  determine what shot the patient needed.
• The nurse did not review the patients
  immunization history and so inadvertently
  administered a Hepatitis A vaccine before the
  date it was actually due to be given.
• Taking the time to carefully review all
  documentation would have prevented this injection
  from being given at the wrong time.

16
Medication ErrorsFailure to Follow the Five
Rights

• Right Time
• Here are some strategies you should use to ensure
  that you are administering medications to your
  patient at the right time
• Keep interruptions and delays to a minimum when
  preparing and administering medications to ensure
  timely administration.
• Know the recommended administration frequencies
  for the drugs you are giving

17
Medication ErrorsCommunication

• Scenarios
• A pediatric patient presented for a routine
  health assessment. The patient was screened and
  placed into a room by the Certified Medical
  Assistant. The CMA informed the nurse that after
  the provider examination was complete, the
  patient would require a Gardasil (HPV) vaccine.
• During the course of the visit the physician made
  the decision not to order the Gardasil (HPV)
  vaccine, and therefore did not place an order
  into KP HealthConnect.
• The nurse, acting on the earlier information
  received from the Clinical Assistant administered
  the Gardasil vaccine although there was not an
  order for it.
• Should the nurse have relied on communication
  from the CMA as the source of information about
  the Gardasil vaccine?
• A physician treating a patient in a busy clinic
  verbally asked a nurse to administer 500mg of
  Tylenol orally to a patient.
• The nurse either mis-heard or mis-interpreted
  what the physician said and administered 500 mg
  of Motrin orally by mistake.
• Communication using verbal orders is the source
  of the majority of medication errors related to
  communication.

18
Medication ErrorsCommunication

• Although the implementation of KP HealthConnect
  has improved the communication of written
  prescriptions we still face significant
  challenges in our region related to communication
  and medication administration.
• We use many ways to communication in our
  organization verbal, email, staff message,
  encounter notes etc.
• Strategies to Improve Communication
• STOP what you are doing and concentrate fully on
  the communication.
• If communicating in person, make eye contact.
  Speak slowly and clearly.
• Listen actively if in person.
• Read thoroughly and carefully if interpreting
  written communication-do not skim the material.
• Ask clarifying questions if there is something
  that is unclear.
• Dont make assumptions! Make sure you understand
  what is being said or asked.

19
Medication ErrorsCommunication

• One of the biggest causes of medication errors
  related to communication in our region is the use
  of verbal orders.
• Here is some additional information regarding
  verbal orders
• The signing of verbal orders is not solely the
  responsibility of the physician, the nurse is
  equally as responsible and perhaps more so.
  Remember, if you write a verbal order and its
  not co-signed it appears in the record that you
  acted without an authenticated order.
• Our regional policy states that verbal orders are
  to be used infrequently and limited as much as
  possible to urgent or emergency situations where
  immediate written or electronic communication is
  not possible.
• This doesnt mean you cant ever take a verbal
  order, they just should not become a routine
  method of communicating orders.

20
Medication ErrorsCommunication

• You may never accept a verbal order for a
  biologic or anti-neoplastic medication for
  initial dosing.
• By policy, verbal orders are to be signed by the
  end of the day or the close of business of the
  medical center/department or by next business
  day if on call.
• Policy Managing Verbal Telephone Orders,
  JR.PC.04
• Nurses may not take verbal orders from other
  nurses.
• Protect yourself and help prevent errors-be very
  cautious and careful with the use of verbal
  orders.

21
Medication ErrorsCommunication

• Here are some important steps that you can take
  to make sure that you receive and carry out
  verbal orders safely
• Do a full read-back of the order to the provider
  at the time he/she gives it to you.
• Read numbers out loud one at a time. For example
  say, Five-zero milligrams of Benadryl orally
  not Fifty milligrams of Benadryl orally which
  may be mis-heard as fifteen.
• Doing a full read-back of the order is a
  requirement according to our regional policy.
• Use the DOT phrase .VO or .TO
• If possible, have a second health care provider
  listen to the verbal order and read-back with you
  to ensure accuracy.
• Make sure that the order makes sense in the
  context of the patients condition
• Record all verbal orders in the patient chart as
  soon as possible. Waiting to document them
  increases the chance that youll forget something
  or transcribe the order inaccurately.
• Work with the ordering provider to make sure the
  verbal order is co-signed in a timely manner.

22
Medication ErrorsKnowledge Deficit

• Scenario
• Following a phone consultation with a patient a
  provider asked the nurse to enter an order in the
  KP HealthConnect system for Septra.
• The nurse entered the order as one pill daily
  for three days-dispense six pills.
• When processing the order the pharmacist noticed
  an error in dosing and called the nurse telling
  her that the correct way to administer Septra is
  one pill twice daily for three days-dispense six
  pills.
• After confirming with the provider the nurse
  entered the order correctly.
• What went wrong here?
• Did the nurse have knowledge of the correct way
  to use verbal orders?
• Did the nurse have knowledge about the proper
  dosing of Septra?
• Educating ourselves about the drugs we are giving
  and our regional policies regarding medication
  administration can help to prevent errors.

23
Medication ErrorsKnowledge Deficit

• Here are some strategies to help you educate
  yourself about the medications you administer and
  our regional policies related to medication
  administration
• Review KPOH Policies and Procedures and Joint
  Regional Policies related to medication
  administration. These are all located on the
  Clinical Policies and Procedures website
  accessible from the KPOH homepage.
• Complete annual competency on Safe Medication
  Administration.
• Use the two on-line drug references KPOH provides
  to access the most up-to-date and reliable drug
  information available. These references are
  LexiComp and Micromedex. There are links to these
  resources on the pharmacy website which can be
  accessed from the KPOH homepage.
• Consult with KPOH pharmacists to learn about
  medications before they are administered.
• Attend in-services or continuing education
  seminars on medication safety.

24
Medication ErrorsDistractions

• Scenario
• A man brings his two children, ages four and six,
  in for routine health assessments. The four year
  old needs immunizations and the six year old does
  not. English is not the primary language for
  this family.
• The nurse asks the man to bring the four year old
  to the immunization room to receive the shots.
  When the nurse enters the room with the vaccines,
  the man is seated in a chair with a small child
  on his lap. The grandmother is also in the room
  with the other child.
• The nurse informs the father that the four year
  old needs immunizations, but the six year old
  does not and asks the father to recite the name
  and birthdate of the four year old, which he
  does.
• After administering the injections the father
  informs the nurse that he is actually holding the
  six year old on his lap and that the four year
  old is with the grandmother. Therefore the six
  year old inadvertently received the vaccines
  intended for his brother.
• Many distractions may have contributed to the
  scenario.
• There were multiple people in the injection room,
  there was a language barrier, there was an
  assumption made that the child on the fathers
  lap was the four year old.
• Taking the time to STOP and think carefully about
  your environment and what you need to stay
  focused and safely administer medications can
  help to prevent errors.

25
Medication ErrorsDistractions

• Here are some strategies to help you avoid
  distractions while you are preparing or
  administering medications
• Focus carefully on what you are doing-remember
  administering medications is one of the most
  serious and significant things you do during your
  work day.
• Prepare medications in areas that are well lit.
• Administer medications in areas that are as quiet
  as possible.
• Do not interrupt a colleague who is preparing or
  administering a medication.
• If you are interrupted when preparing or
  administering a medication, simply say please
  wait a minute and continue with your work.
• Do not have conversations with co-workers,
  physicians, patients or visitors while you are
  preparing or administering medications. If
  someone attempts to speak with you simply say,
  please wait a minute and continue with your
  work.
• We must all work together to respect the
  medication preparation and administration
  processes and not distract each other from these
  important tasks.

26
Medication ErrorsLook Alike/Sound Alike
Medications

• Scenarios
• A physician ordered 2 mg of morphine
  intravenously for a patient in a busy clinic.
  The nurse inadvertently obtained and administered
  2 mg of hydromorphone (Dilaudid).
• The names of these two drugs are very similar and
  unfortunately they are often confused. Although
  they are both opioid pain relievers Dilaudid is 5
  times stronger per milligram than morphine, so
  this patient received the equivalent of 10 mg of
  morphine intravenously.
• A nurse received an order to administer tetanus
  toxoid to a patient. The department was out of
  the vaccine so another clinical staff member
  filled out a requisition and went to the pharmacy
  to pick up the medication, which she delivered to
  the administering nurse.
• The nurse administered the vaccine to the
  patient, but after doing so realized that she had
  administered Td (tetanus/diptheria combination
  vaccine) instead of tetanus toxoid.
• The highest number of regional errors related to
  look alike/sound alike medications involve the
  administration of vaccines.

27
Medication ErrorsLook Alike/Sound Alike
Medications

• Look alike/sound alike drugs are defined as drugs
  that have names or packaging that are very
  similar and place them at higher risk of being
  confused with each other.
• Here are some strategies to help you avoid errors
  related to look alike/sound alike medications
• Look carefully at exactly what you are
  administering to make sure it is correct. Dont
  rely on the fact that you know what it looks
  like.
• Take time to compare the medication you select to
  the printed order.
• Store medications properly to minimize the
  likelihood that they will be confused or mixed
  up. The statements below are taken from our
  regional policy, Medication Administration
  General Guidelines, and outline proper medication
  storage.
• Medications shall be stored in such a way that
  allows for the physical
• separation of medications (i.e. bins,
  separate shelves, drawers, dividers, etc.) in
  both cabinets and medication refrigerators as
  follows
• Separation by routes oral, injectable and
  topical medications
• Separation by dose medications of the same name
  with different dosages.
• Separation of look alike/sound alike medications.
  
• Medications stored in the refrigerator shall be
  separated and stored in the interior of the
  refrigerator, and not in the door

28
Medication ErrorsHigh Alert Medications

• High Alert Medications are drugs that carry an
  increased risk of injury or death when they are
  improperly prepared or administered, and
  therefore require special safeguards to reduce
  the potential for errors.
• High alert
  medications will be dispensed from the pharmacy
  with this sticker.
• The administration of a high alert medication
  always requires an Independent Double Check, a
  Time Out at the bedside and additional safeguards
  as outlined in the KPOH High Alert Medication
  Policy.
• Independent Double Check Two nurses separately
  calculate dosages and verify the other rights
  of administration and then compare their answers.
  The check should not be done together!
• Time Out A brief final check involving the
  patient and at least two licensed persons. The
  patients identity and the medication being given
  are verified. Additionally, allergies are
  checked, the administration of required
  pre-medications is confirmed and overall
  agreement is reached before the medication is
  administered.
• The policy and regional list of High Alert
  Medications are available on the Clinical Policy
  and Procedure website under Joint Regional
  Policies.

29
Medication ErrorsYour Rights As A Nurse

• As a professional clinician tasked with safely
  administering medications, YOU have rights
  regarding safe medication administration.
• The Six Rights of Nurses were developed on behalf
  of the Massachusetts Nursing Association (MNA)
  approximately 10 years ago and presented to the
  Joint Committee on Health Care. Today these
  rights have become widely accepted and are
  promoted by such organizations as the Institute
  for Safe Medication Practices.
• Here are YOUR rights as a nurse administering
  medications.
• You have
• The right to a clear and complete order
• The right to have the correct drug, route, form
  and dose of medication dispensed
• The right to have access to drug information
• The right to have policies to guide safe
  medication administration
• The right to administer medications safely and to
  identify system problems
• The right to stop, think and be vigilant when
  administering medications

30
Conclusion

• As nurses one of the most serious and
  significant things that we do in our practice is
  administer medications to our patients. There
  are many factors in the medication preparation
  and administration processes that may contribute
  to an error, therefore it is vitally important
  that we understand how errors are made and
  strategies to avoid them.
• The top five categories of medication errors made
  in KPOH are Failure to follow the five rights of
  medication administration, communication issues,
  knowledge deficits regarding various medications,
  distractions during preparation and
  administration and confusion of look alike/sound
  alike medications.
• Understanding how these mistakes occur and being
  able to employ prevention strategies in real-time
  will help us to avoid errors and create a safe
  care environment for our patients.

30
31
References

• Gandhi, T.K., Borus, J., Seger, A.C., Peterson,
  J., Burdick, E.,Bates, D.W. (2003). Adverse drug
  events in ambulatory care. New England Journal of
  Medicine, 348, 1556-1564.
• Hughes, R.G. Blegen, M.A. Patient safety and
  quality an evidence-based handbook for nurses
  chapter 37, medication administration safety.
  Retrieved from www.ahrq.gov/qual/nurseshdbk/docs.
  September, 2011.
• Institute for Safe Medication Practices. ISMP
  medication safety alert nurses rights regarding
  safe medication administration, 5(7), July 2007.
• Trended unusual occurrence reports for medication
  errors involving nurses, Kaiser Permanente
  Mid-Atlantic States Region. June-September, 2011.

31
32
Policies for KPOH

• Joint Regional Policies

• Health Plan Policies

• JR.PC.04 Managing Verbal and Telephone Orders

• HP.NUR.GEN.13 Managing Written Orders
• HP.NUR.GEN.55 Immunizations and Injections
• HP.RC.REG.II-H Patient Identification Section
  3.0
• Policy HP.AS.SFTY.10 Patient Identification