Medication Error Training Material

                                                 Medication Error Training Material 

Medication errors: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional. Such events may be related professional practice, procedures, and systems, including prescribing; communication; labeling, packaging, and nomenclature; dispensing; distribution; administration; education; monitoring and use.

 

Types of errors:

Order Error – Types of ordering errors include: inappropriate medication selected, inappropriate dose, illegible order, duplicate order, order not dated/timed, wrong patient/chart selected, contraindications, verbal order misunderstood, verbal order not written in the drug chart, wrong frequency, route, illegible writing, therapy duration, alert information bypassed or use of nonstandard nomenclature or abbreviations.

Transcription error –Transcription involves both the orders that are manually transcribed onto manual record (e.g. Drug chart). Types of transcription errors include: wrong medication, time, dose, frequency, duration, rate patient/chart, verbal order misunderstanding, verbal orders not entered into patient case sheet.

Preparation/Dispensing Error – Types of preparation and dispensing errors include: Inaccurate Labeling, wrong quantity, medication, dose, diluents, formulation, expired medication, Pyxis refill error, and delay in medication delivery.

Administration Error – Types of administration errors include: Wrong patient, dose, time, Medication, route, rate, extravasation (may be an ADR) and unauthorized dose given

 

Procedure for the Identification and Review of any Medication Errors:

The inpatients who are administered different drugs need monitoring during their stay in the hospital. This is of paramount importance in the case of patients undergoing treatment in the ICU’s. Certain drugs can produce serious immediate or delayed side effects. Patients with past history of drug allergies shall be identified. If drugs prone to produce allergic reactions, it should be done with caution. A small dose of the drug is given intra dermal and marked with time, if any drug allergy is noted the main dose administration is withheld and the doctor shall be informed. Drug reactions producing cardiac, neurological, pulmonary, skin etc. side effects shall be promptly identified and the concerned doctor should be promptly informed and remedial action is taken. All events and actions taken should be recorded by the concerned nurses in the patient’s case sheet and signed with date. The medical superintendent and the nursing superintendent or the nursing supervisor shall be notified in cases where wrong medications are administered to a patient, or there has been negligence on the part of the nursing staff in following directions of drug administration and necessary investigations should be initiated. When Intra Venous (I.V) medications are given the nurse must be present along with the patient to monitor the progress or note any undue side effects. Starting and discontinuation of I.V medication shall be done by the treating nurse and the details should be noted in the case sheet with sign, date and time. The nurse should enquire about the patient’s welfare from time to time after such treatment and make sure that everything has been running smoothly