MEDICATION ERRORS: AN
INTERDISCIPLINARY APPROACH
ROBERTA MCINTYRE, MSN, RN
Nursing Service Consultant
Office of Developmental Programs
Western Region
GOALS:
1. Define medication error
2. Identify types of medication errors
3. Identify strategies to reduce medication errors
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
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
THE FIVE RIGHTS
Right person
Right medication
Right dose
Right route
Right time
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
ABBREVIATIONS AND SYMBOLS
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
METHODS TO INVESTIGATE ERRORS
DEBRIEFING PROCESS
1. Approach Staff
2. Ask staff
3. Ask staff
ACHIEVED OBJECTIVES
Agency intent
One on one time with staff
Uncover additional issues
Staff ownership
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
HCSIS REPORTING SYSTEM
WHY REPORT ERRORS
Potential risks
Actual errors
Cause of errors
Prevention
WHAT TO REPORT
Risk
Near misses
Errors, no harm
Errors, harm
INFORMATIVE REPORTS INCLUDE:
HOW
WHY
SUGGESTIONS
HCSIS SYSTEM
WHY
WHAT
AGENCY RESPONSE
ANY QUESTIONS?
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
