The Practical Nurses Role in
Preventing
Medication Errors
8th EditionTextbook Chapter 9
Rev KBurger 0608
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Medication Errors
• 10 percent to18 percent of hospital
injuries attributed to medication errors
• 44,000 to 98,000 people die in U.S.
hospitals annually due to medication
errors
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Medication Errors
• Effects of medication errors
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Increase length of stay
Increased cost
Patient disability
Death
Nurse’s personal and professional status,
confidence, and practice
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Nursing Responsibilities
Legal and Ethical
• Nurses are liable for their actions,
omissions, and for those duties they
may delegate to others.
• They are personally
responsible…legally, morally and
ethically…for every drug they
administer.
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Nursing Responsibilities
• Obtaining current knowledge base of drugs
• Referring to authoritative sources in
professional literature (less than 5yrs old)
• Questioning a drug order that is unclear or that
appears to contain an error
• Refusing to administer a drug if there is a
reason to believe it will be harmful.
• Performing correct techniques and precautions
• Monitoring client response and documenting
drug effects
• Patient and family education
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Nursing Responsibilities
continued
• Know Information about the medication
Action – side effects – appropriate dose
Age specific considerations – routes
• Know Information about the client
What other medications are they taking
ALLERGIES or other problems w/ meds
Gag reflex – Impaired swallowing
Dietary and/or Fluid restrictions
Cultural and/or religious influences
Genetic factors
Vital signs
Lab values – renal & liver function / protein & albumin
Age
Pregnant/breast feeding
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Nursing Responsibilities
continued
• Using correct techniques of preparation and
administration to deliver medications safely.
• Monitoring the client for therapeutic and nontherapeutic effects of the drug
• Client education for safe and accurate selfadministration of the drug.
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Legal Controls in
Pharmacology
Purpose and Scope of Legal Controls:
• Protect public health and safety
• Laws govern testing, production,
distribution, prescription and the
administration of drugs.
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Federal Medication Laws
1906 Pure Food & Drug Act
Disclosure of dangerous ingredients
1912 Sherley Amendment
No fraudulent claims of action
1914 Harrison Narcotic Act
Established regulations for narcotics
1938 Food,Drug,CosmeticAct
Drugs must be tested and proved safe
1952 DurhamHumphrey Amendment
Established list of drugs needing RX
1962 Kefauver-Harris Amendment
Drugs must be proven effective
1970 Controlled Substances Act
Strict controls on distribution ***
1978 Drug Regulation Reform Act
Shortened drug investigation time
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***Controlled Substance Act
• Designed to promote treatment and prevention of drug
dependence
• Established controls such as:
-Prescribers are registered with the DEA. A registry
number is issued to each person and is renewed
annually.
-Complete written records of all drugs prescribed must be
kept for two years. Pharmacists record each sale in
triplicate. Schedule II drug prescriptions cannot be
renewed.
-DEA (Drug Enforcement Agency) monitoring
• Health care agencies must establish policies to comply
with Federal law.
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Controlled Substance Act - continued
-All units have a record of every controlled
drug on the unit and two nurses at the
change of every shift count all drugs.
-All controlled drugs are stored using a
double lock system. Keys to medication
areas are under the control of nurses on the
unit.
-Discarding of controlled substances must be
witnessed by another nurse
-Written renewal orders are required every 72
hours for narcotics and schedule II & III
drugs.
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Control Schedule
Drugs with a significant potential for abuse
are classified into 5 categories or
schedules:
Schedule I: highest potential for abuse
Illicit drugs (Heroin, LSD, Marijuana)
Schedule II: (Morphine, Dilaudid)
Schedule III: (Vicodin, Meperidine)
Schedule IV: (Valium, Xanax)
Schedule V: lowest potential for abuse
(OTC cough suppressant
w/codeine)
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Drug Information Resources
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Agency pharmacists are an appropriate resource
for obtaining drug information on the job.
Nursing drug handbooks: contain drug information
along with nursing considerations.
Physician's Desk Reference (PDR) Contains
manufacturer's descriptions (package inserts) which
are written using FDA standards, but may be slanted
in favor of the drug being described.
Package Inserts: Required by law for insertion with
each new drug and must include a description,
indications, precautions, dosage, and
contraindications.
Electronic databases and Internet
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Adverse Drug Events (ADE)
• An undesirable occurrence related to
administration of or failure to administer a
prescribed medication.
• General term that includes all types of clinical
problems encountered regarding medications
including:
- adverse drug reactions (ADRs)
adverse effects
allergic reaction
idiosyncratic reaction
-medication errors (MEs)
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Adverse Drug Reaction ADR
• Any unexpected, undesired or excessive
response to a medication given in therapeutic
dosages) that results in:
- temporary or serious harm or disability
- admission to hospital, higher level care
or prolonged stay
- death
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Adverse Drug Reaction
continued
• Adverse Effects:
-Expected side effects (ie stomach upset)
-Dose-related reactions (ie liver or renal
impairement, geriatric and/or pediatric
considerations)
-Drug/Drug or Drug/Food interactions (ie
potentiation of drugs by another drug, or drug
not absorbed well with food)
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Adverse Drug Reaction
continued
• Allergic Reaction:
-Hypersensitivity ( ie: rash, anaphylaxis)
• Idiosyncratic Reaction:
-abnormal and unpredicted response
specific to an individual (ie: confusion
and antibiotics)
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Nursing Measures to
Prevent Medication Errors
Order interpretation, reconciliation, and confirmation
• Never assume anything about a drug order.
CLARIFY, CLARIFY, CLARIFY
• Make sure medication orders contain all (7) parts
• Minimize use of verbal or telephone orders. If
used, spell all drug names and repeat to confirm
( NOT LPN Scope)
• Check Medication Administration Records (MAR)
to the original prescriber order as per agency
protocol.
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Nursing Measures to Prevent
Medication Errors
Safe Medication Administration
• USE THE SIX RIGHTS
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Right drug
Right route
Right patient
Right dose
Right time
Right documentation
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Right Patient
• Correctly identify patient prior to
medication administration using at least
(2) identifiers.
– Compare medical record number (MRN) on client
armband with medication administration record
(MAR)
– Ask the patient to state his name & DOB
– Compare picture to patient if available
– Technological advances to prevent errors
Bar-coding
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Right Patient
• Tell patient at time of administration
what medication and dosage is being
administered. Briefly explain therapeutic
use of each medication
– Patient may question drug or dosage
– Re-confirm the drug order in chart and MAR
– Provides an opportunity to do medication teaching
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Right Drug
The (3) Checks
• Check medication label 3X
– On first contact with drug; when removing from
medication box
– Prior to measuring
• Pouring, counting, or withdrawing
– Just prior to administration; when returning to
medication box
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Right Drug
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Be aware of distractions
Do not multitask during drug administration
Use bar-coding scanning when available
Be knowledgeable about the drug’s actions,
indications, and contraindications
• Be extremely vigilant about known
HIGH ALERT MEDICATIONS
• Be alert to Look-a-like , Sound-a-like medications
• Do not accept Drug Name Abbreviations
(IE MS for Morphine Sulfate )
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HIGH ALERT MEDICATIONS
Sound-a-like Look-a-like DRUGS
• ISMP List of High-Alert
Medications
• Top (5) drugs involved
in harmful errors
PINCH
HYPERLINK
Potassium
Insulin
Narcotics
Coumadin
Heparin
• ISMP List of Confused
Drug Names
• Example:
HYPERLINK
Tegretol versus Toradol
(anticonvulsant versus
antiinflammatory)
Paxil versus Plavix
(antidepressive versus
antiplatelet)
• Use TALL-MAN letters
• Know both generic and
trade names of drugs
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Right Route
• Consult a drug information source to
confirm correct route
• Do not accept incorrect abbreviations:
sq or sc – WHAT IS PREFERRED?
JCAHO Do not Use List
• Example: Be careful of:
IVP versus IVPB
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Right Route
• May need to change or clarify forms or
routes of the drug for safe medication
administration
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NPO status
Client inability to swallow pills
Nasogastric or surgically inserted tubes
Time-released or enteric-coated medications
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Right Time
• Order should include frequency of
administration
• Administer medications within 1 hr of
prescribed time ( or per facility guidelines)
• Use safe abbreviations
Do not accept: QD or QOD
WHAT IS PREFERRED???
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Right Dose
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Carefully read and clarify drug orders
Do not accept illegible handwriting
Do not accept leading or trailing zeroes
Do not accept U or IU
WHAT IS PREFERRED?
• Recheck labels 3 times!
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Right Dose
• Have two nurses double-check high
alert medications
• Consult drug references
• Consider developmental age of client
• Accurate dosage calculations
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Right Documentation
• Document IMMEDIATELY after
administration
NEVER DOCUMENT BEFORE!!!
• Omitting documentation can result in
over or undermedication
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Ethical Considerations
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Respect of patient rights
Vigilant patient advocacy
Maintenance of knowledge and skills
Dedication to improvements in practice
Notification of patients regarding errors
Whistle-blowing
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Genetic Factors
• Age-related Factors:
Pediatric-
-absorption, distribution, metabolism, excretion differences
- weight based dosing
Geriatric
- decreased body fat, lean muscle, water
- decreased plasma proteins
- diminished GI motility and absorption
- slower liver and kidney function
• Inherited Factors:
– Slow versus Fast Acetylators
differences in metabolism of drugs
(IE: Asian Americans need lower doses of the antiaxiety drug
Haldol)
– Known Genetic group differences
(IE: African Americans respond better to CCB drugs for
hypertension)
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Cultural Considerations
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Varying health beliefs and practices
Folk and/or home remedies
Religious practices
Dietary practices
RESPECT for client’s cultural context
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