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