To Err is Human… To Ignore may lead to Death

Medication Errors – F 332-the facility must assure that it is free of medication error rates of 5 % or greater. F333 states the facility must assure that residents are free of any significant medication errors.

According to studies drug errors are so common and prevalent in hospitals, nursing homes and long-term care facilities that it has been estimated that an average of one mistake per patient per day is made. It is estimated that there are 800,000 medication errors in long term care settings alone. Many of the errors may not lead to serious injury however it takes just one serious error to lead to a disability or death. All medications should be considered equally as important which would include OTC’s, herbal supplements, vitamins and minerals.

The administration of a wrong drug, patient, strength, dose, omission or continuing a discontinued medication is often the case in many medication errors. These often occur when prescribing, transcribing, illegible handwriting by physician and or nursing and dispensing of the medications. When reported, a medication error report form is completed with an investigation. However, equally important is observing brand/generic names; look-alike/sound alike medications; dosage forms; interactions; side effects; cautionary warnings and times of administration which also lead to medication errors and potential patient harm.

When reporting errors the following should be included:
1. Describe the error or preventable adverse drug reaction. What went wrong? Include the number of doses that was involved in the incident.
2. Was this an actual medication error (reached the patient) or was this a potential error that did not yet reach the patient.
3. Patient outcome.
4. The Brand/Generic name of all products involved. Include Rx# for pharmacy tracking.
5. The dosage form, concentration and strength.
6. How was the error discovered?
7. Preventative measures to ensure that it does not happen again.
8. Was it necessary to contact a licensing agency?
9. Physician/Patient/Family notification.
10. Post monitoring of the patient for side effects as per facility policy.

Medication orders 101…
All licensed personnel who are able to write or take medication orders are taught basic information. The reality is that professionals in nursing homes are often multi-tasking, fielding phone calls or being interrupted on a constant basis. However, there is a standard that must be met in order for medications to be communicated to the pharmacy for timely processing. The following information is required in order for the pharmacy to distribute the medication promptly and accurately to the facility.
a. Physician’s name
b. Date of birth
c. Diagnosis
d. Allergies
e. Patient’s location-facility; room #
f. Date of order
Most importantly all information should be printed legibly

The best method of prevention is education and auditing…
There is nothing more sobering to a nurse passing medications then to have someone watching them. During the annual state survey everyone is prepared and following guidelines. But what happens during the interim months? Each facility should organize a quality assurance system including auditing the medication system. Depending on the dispensing system utilized by each facility, the label and package should be checked against the doses given by the staff on the corresponding MAR for accuracy. Medication observation techniques should be incorporated by administration with educational feedback to the nurses on their technique and knowledge of the medications. Include your pharmacy consultant and pharmacy provider for additional medication observations. Audit the medication carts in order to see if medications are being given as prescribed. Review the narcotic sheets to ensure compliance. Randomly observe staff for observance of state and federal guidelines. It may take some time out of your day but may save a life in the end.

28. June 2010 by Ruth Folger Weiss
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