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Safe Medication Administration

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TOGETHER, WE CAN MAKE THE ORDINARY EXTRAORDINARY Safe Medication Administration Ohio Regional Clinical Competency Adapted for use by Nursing Administration – PowerPoint PPT presentation

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Title: 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
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