Medication Error Prevention Strategies
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Preventing Medication Errors In Nursing
Linkedin Pin it More sharing options Linkedin Pin it Email Print When Jacquelyn Ley shattered her ways to prevent medication errors elbow on the soccer field, her parents set out to find her the best care in Minneapolis. "We drove past five other hospitals to how to prevent medication errors in hospitals get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9
How To Reduce Medication Errors By Nurses
at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.Carol Ley slept in her daughter's hospital room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but
Reducing Medication Errors In Nursing Practice
she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."Ley was pleased with the way the hospital handled the error. "They came right out and said the morphine pump was incorrectly programmed, they told me the steps they were going to take to make sure Jacquelyn was OK, and they also told me what they were going to do to make sure this kind of mistake won't happen again. And that's very important to me." The hospital began using pumps that are easier to use and revamped nurses' training. Ley believes there were many contributors to the error, including the fact that it was Labor Day weekend and there were staff shortages. "It goes to show that this can happen to anyone, anywhere," says Ley, who now chairs the board of the National Patient Safety Foundation.Multiple FactorsSince 1992, the Food and Drug Administration has received nearly 30,000 reports of medication errors. These are voluntary reports, so the number of medication errors that actually occur is thought to be much higher. There is no "typical" medication error, and health professionals, patients, and their families are all involved. Some examples:A physician ord
Let’s resolve to do better, highlighted the fact that, despite error-prevention efforts, look-alike drug names, sound-alike drug names, and look-alike packaging continue to be a common source of medication errors. Selecting the best strategies to reduce medication errors error-prevention strategies is not an easy task. Even when system-based causes such as
Medication Errors In Nursing 2014
look- and sound-alike issues have been identified, it may be unclear which error-prevention strategies will be most effective. Listed below and medication errors articles in Table 1 are examples of error-prevention strategies in order of effectiveness for creating lasting system changes for safe medication use. Those listed first are more powerful because they focus on changes to the http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm143553.htm system in which individuals operate. As the list descends, strategies that target system changes, but rely in some part on human vigilance and memory are presented. Strategies toward the end are familiar and often easy to implement, but rely entirely on human vigilance. Fail-safes and constraints are among the most powerful and effective error-prevention strategies. They involve true system changes in the design of products or how individuals https://www.ismp.org/newsletters/ambulatory/archives/200602_4.asp interact within the system. Examples outside of healthcare would include the inability to start a car while the gearshift is in reverse or using fingerprint verification to enter a building or computer system. At a community pharmacy where the pharmacy computer system is integrated with the cash register, a fail-safe would prevent the clerk from “ringing up” the prescription unless final verification by a pharmacist was noted in the system. Forcing functions are procedures that create a “hard stop” during a process to help ensure that important information is provided before proceeding; often referred to as a “lock and key” design. For example, an electronic prescribing system in a physician’s office that requires the indication to be entered for each medication before it is processed and sent to the pharmacy; a pharmacy computer system that prevents overriding selected high-alert messages without a notation (e.g., entry of the patientspecific indication for selected error-prone medications); or a bar-code scanning system that does not allow final verification of a product without a positive match between the selected product and the profiled medication. Automation and computerization of medication-use processes and tasks can lessen human fallibility by limiting reliance on memory. Examples include use of electronic prescr
DisorderCardiovascular HealthCOPDCough and ColdDiabetesEpilepsyFluGlaucomaGoutHeart FailureHepatitis CHIVInfectious DiseaseNeutropeniaOsteoporosisPain ManagementVitamins and SupplementsWomen's HealthContinuing EducationCommunityContributorsBlogsPublications 10 Strategies for Minimizing Dispensing Errors Rama P. Nair, RPh; Daya Kappil, RPh; and Tonja M. Woods, PharmD Published Online: Wednesday, January http://www.pharmacytimes.com/publications/issue/2010/january2010/p2pdispensingerrors-0110 20, 2010 Mrs. Nair and Ms. Kappil are both PharmD candidates at the University of Florida Working Professional Doctor of Pharmacy Program. Dr. Woods is a clinical assistant professor at the University of Wyoming School of Pharmacy, Laramie. Medication errors are a leading cause of mortality in the United States.1 Dispensing errors medication error account for ~21% of all medication errors.2 In addition to causing serious morbidity and mortality, dispensing errors increase the economic burden on society by adding to health care costs. Faulty dispensing may also result in litigation, which can be expensive and lead to increased costs for professional liability insurance coverage. Dispensing in medication errors in error is traumatic for the pharmacist as well as the patient; therefore, the goal of every pharmacy is to reduce the amount of dispensing errors. Fortunately, only about two thirds of dispensing errors reported actually reach the patient, with relatively few causing harm.2 Dispensing errors include any inconsistencies or deviations from the prescription order, such as dispensing the incorrect drug, dose, dosage form, wrong quantity, or inappropriate, incorrect, or inadequate labeling.3 Also, confusing or inadequate directions for use, incorrect or inappropriate preparation, packaging, or storage of medication prior to dispensing are considered to be errors.3 Errors occur at a rate of 4 per day in a pharmacy filling 250 prescriptions daily, which amounts to an estimated 51.5 million errors out of 3 billion prescriptions filled annually nationwide.4 Dispensing errors committed by individuals are often the result of error-prone systems and processes.5 Therefore, the main strategy to reduce dispensing errors is to implement a systemoriented