Medication Error Documentation
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therapy or failing to receive it as prescribed or intended. Medication errors happen for many reasons. However, failing to follow the six rights of medication administration is probably the most basic cause. documenting medication errors in the medical record Whether or not the patient was harmed or had an adverse reaction as
How To Document Medication Administration
a result of the error, all medication errors must be reported, not only for patient safety but for quality-improvement
Medication Administration Documentation Example
purposes. When you or a colleague makes a medication error, the patient’s safety and well-being are your first priority. Monitor the patient closely and notify the provider and your nurse manager as
What Are Examples Of Common Medication Errors?
soon as possible. Once the patient is stable, the person who made the error must complete an incident, variance, or quality-assurance report as soon as possible, but generally within 24 hours of the incident. The report should include the following information and any additional information required by facility policy: patient information, the location and time of the incident, a description of what happened and what medication error what to do after was done about it, the condition of the patient, and the nurse’s signature. The incident report does not become a permanent part of the patient’s medical record; do not mention it in your documentation on the patient’s chart. The intent of this is not to hide the fact that an error occurred, but to protect the nurse and the facility. Depending on the error that occurred and the outcome, the facility may be required to report the incident to the Joint Commission. Nurses should feel comfortable reporting a medication error and not fear disciplinary action. Incident reports should not be used for disciplinary purposes but to improve systems and processes. Managers who use incident reports for disciplinary purposes run the risk of increased failure to report errors and of the same mistakes being made again and again. Medication incident report form References Bentz, P. M., & Ellis, J. R. (2007). Modules for basic nursing skills (7th ed.). Philadelphia: Lippincott Williams & Wilkins. p. 828. Duell, D. J., Martin, B. C., & Smith, S. F. (2004). Clinical nursing skills: Basic to advanced skills (6th ed.). Upper Saddle River, NJ: Pearson Education, Inc. pp. 518-519.
Times Practical Cardiology Urology Times BusinessPractice Management Health Law & Policy Healthcare IT E-Books Practice Management Whitepapers Webinars EDUCATIONCME CPE Careers Contact UsAdvertise About Us Email us / Questions Log In | Register Search this which should be the first step if a medication error occurs quizlet site: CONNECT: Facebook linkedinEmail Increase FontSharebar PREVObese women can add reduced incontinence med error incident report to b ...Obese women can add reduced incontinence to b ...Predictors of contralateral breast cancer ide ...NEXTPredictors of contralateral medication error incident report sample breast cancer ide ... Modern medicine Documentation and litigation: Best practices for nurses February 01, 2009 By Edie Brous, RN, JD, MS, MPH RN Radio! Listen to a free podcast http://www.atitesting.com/ati_next_gen/skillsmodules/content/medication-administration-1/equipment/error.html featuring an interview with nurse attorney and article author Edie Brous. What you see on "CSI" or "LAW AND ORDER" may give you the idea that medical malpractice attorneys routinely use DNA, voice print analysis, and high-tech laboratory assays to prosecute or defend lawsuits. For the most part, this is not the case. With the exception of whatever witness testimony may be http://www.modernmedicine.com/modern-medicine/news/modernmedicine/modern-medicine-feature-articles/documentation-and-litigation-be available, the only evidence in a malpractice case is the medical record. The patient's chart is used to demonstrate accreditation and regulatory compliance, and to make reimbursement determinations. It also is examined by licensing boards in deciding disciplinary action. For these reasons, it is imperative that nurses consistently use acceptable documentation practices. BASICS. The medical record must reflect an accurate chronology of events. Without exception, every entry must be dated (complete with year), timed (with a.m. or p.m., unless using military time), and signed with last name and status. It is not adequate to sign once on a page, or after multiple notes. Use the same timepiece when recording entries. Do not use multiple sources, such as your watch, the clock in the patient's room, the cardiac monitor, the computer, etc. Using different timepieces can create the appearance of events occurring out of sequence, or of delays that did not really exist. This is particularly important with time-sensitive events such as active labor or resuscitation efforts. Though legibility issues have been reduced somewhat with the adoption of computerized entries, they remain p
StatisticsEventsMagazinePast IssuesBlogSubscribeFor EmployersMedia KitPost a JobRegisterFAQsPost a Job Select Page 10 Strategies for Preventing Medication Errors by Dexter Vickerie | Dec 31, 2015 | Blog | 0 comments It is important for all nurses to become familiar with various strategies to prevent http://minoritynurse.com/10-strategies-for-preventing-medication-errors/ or reduce the likelihood of medication errors. Here are ten strategies to help you do just that.1. Ensure the five rights of medication administration. Nurses must ensure that institutional policies related to medication transcription are followed. It isn’t adequate to transcribe the medication as prescribed, but to ensure the correct medication is prescribed for the correct patient, in the correct dosage, via the correct route, and medication error timed correctly (also known as the five rights).2. Follow proper medication reconciliation procedures. Institutions must have mechanisms in place for medication reconciliation when transferring a patient from one institution to the next or from one unit to the next in the same institution. Review and verify each medication for the correct patient, correct medication, correct dosage, correct route, and correct time against the transfer orders, or error incident report medications listed on the transfer documents. Nurses must compare this to the medication administration record (MAR). Often not all elements of a medication record are available for easy verification, but it is of paramount importance to verify with every possible source—including the discharging or transferring institution/unit, the patient or patient’s family, and physician—to prevent potential errors related to improper reconciliation. There are several forms for medication reconciliation available from various vendors.3. Double check—or even triple check—procedures. This is a process whereby another nurse on the same shift or an incoming shift reviews all new orders to ensure each patient’s order is noted and transcribed correctly on the physician’s order and the medication administration record (MAR) or the treatment administration record. Some institutions have a chart flag process in place to highlight charts with new orders that require order verification.4. Have the physician (or another nurse) read it back. This is a process whereby a nurse reads back an order to the prescribing physician to ensure the ordered medication is transcribed correctly. This process can also be carried out from one nurse to the next whereby a nurse reads back an order transcribed to the physician’s order form
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