Medication_Administration-2

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California State University, Northridge *

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Medicine

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Dec 6, 2023

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Medication Administration Misty Gunderson, Ricardo Gutierrez, Saina Habibi, Almira Javier, Adam Kiswardy, Kristalyn Lima, Mariah Little, Margareta Lupan

Objectives ● Recognize the most common and major types of medication administration errors ● Discuss and describe best practices to reduce/prevent medication administration errors ● Identify risk factors that lead to medication administration errors ● Identify the steps to be taken to reduce medication administration errors ● Increase competency about new and current policies in regards to prevention of medication errors

Medication Errors According to an article by AMCP.org in 2019, “ medication errors were among the most common medical errors, harming at least 1.5 million people in the US every year.” The Pharmaceutical Journal of England: “Reducing medicine-related harm requires a clear understanding of where and when errors occur” - So… where do we go from here?

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Vanderbilt Nurse Recently the danger of med errors has hit the news due to a former nurse by the name of RaDonda Vaught. Ultimately her administration of a medication led to the death of one of her patients. Reading the reports of the case we can see that there were several things that led to the death of her patient: - She overrode the system to extract a medication (common for nurses at that time to override the system in order to get drugs. The hospital had recently updated an electronic records system, which led to delays in retrieving medications from the automated drug dispensing cabinets) - She did not scan the medication against the MAR (no scanner in the imaging area for Vaught to scan the medication against the patient's ID bracelet. RaDonda was ultimately charged with reckless homicide and felony abuse of an impaired adult - What went wrong in this case? - Who is at fault? ]

Common Causes Systems : - Design Failures People : - Human Error - At Risk Behavior - Reckless Behavior - Willful Harm - Poor Communication - Entering Wrong Orders - Complacency & Carelessness - Understaffing & Distractions - System Errors - Multidisciplinary approach - Sources of Injury - Unclear about dose - Misread label- guess by first letter - Recognize by looking - Misnaming medications - Misunderstanding spoken instructions - Polypharmacy

Who does it affect This is not some far off issue, this could affect you… or a loved one. Most common adverse events with medication administration happen in: ● elderly patients ● patients with lowered liver or kidney function ● polypharmacy ● large number of additional comorbidities

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Where does Henry Mayo Fall Scoring: When looking at Leapfrog Hospital grading system, Henry Mayo has actually scored a D. The medication administration error scoring was a whooping 45/100. If you were a patient, how would this statistic make you feel?

Henry Mayo’s Policy on Prevention of Medication Errors ● Multidisciplinary team policy ● Approved abbreviations ● Confirmation by pharmacy ● Resources ● Unit dose system ● Storage safety ● Return unused/ DC’ed medications to pharmacy ● Educating the multidisciplinary team (seminars, case studies, debriefing)

National Solution 5 Rights The World health Organization knows this is an issue and has proposed laws and protocols to decrease med errors. These include… - Drug Name - Barcode Scanning - Patient Education

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Solution - Double scan medications, scan when taking out of the Medication dispenser - Omnicell lists high alert medication - 5 patient rights - Double RN sign off on high alert medication - Thoroughly educate patients about their medications https://www.henrymayo.com/app/files/public/5e1c61ac-7325-4a88-a635-40dd122160a1/Medication%20Educati on/Medication-Lean-Tool-v6.pdf Speak Up! Don’t create a culture of fear.

Our solution (cont’d) This is a multidisciplinary problem. - Correct physician orders and adequate communication And have physicians put in if possible - Keep colleagues and yourself accountable - Safe Staffing If you aren’t able to scan a drug, double check with another RN or pharmacy Reduction of interruptions and distractions, “no-interruptions zone” We propose: Dual fingerprint sign-off at bedside

Review of Literature

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References Aldhafeeri, N. A., & Alamatrouk, R. (2019). Shaping the Future of Nursing Practice by Reducing Medication Error. Pennsylvania Nurse , 74 (1), 14–19. Center for Drug Evaluation and Research. (n.d.). Working to reduce medication errors . U.S. Food and Drug Administration. Retrieved May 3, 2022, from https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce- medication-errors Hospital details table . Table. (n.d.). Retrieved May 3, 2022, from https://www.hospitalsafetygrade.org/table-details/h enry-mayo- newhall- hospital Kelman, B. (2022, March 25). Former nurse found guilty in accidental injection death of 75-year-old patient . NPR. Retrieved May 3, 2022, From https://www.npr.org/sections/health-shots/2022/03/25/1088902487/former-nurse-found-guilty-in-accidental-injecti on-death-of-75 -year-old-patient Laatikainen, O., Sueck, S., & TuReinen, M. (2021). Medication-related adverse events in health care-_what have we learned? A narrative overview of the current knowledge. European Journal of Clinical Pharmacology, 78(2), 159-170. https://doi.org/10.1007/s00228-021-03213-x

References (continued…) Mayo Foundation for Medical Education and Research. (2020, September 3). Protect yourself from medication errors . Mayo Clinic. Retrieved May 3, 2022, from https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/medication-errors/art-20048035 #:~:text=The%20 most%20common%20causes%20of,and%20medications%20that%20look%20alike Medication errors and adverse drug events . Patient Safety Network. (n.d.). Retrieved May 3, 2022, from https://psnet.ahrq.gov/primer/me dication-errors-and-adverse-drug-events Medication errors . AMCP.org. (n.d.). Retrieved May 3, 2022, from https://www.amcp.org/about/managed-care-pharmacy-101/co ncepts-managed-care-pharmacy/medication-errors The Facts • Patient Safety Movement. (2022). Retrieved 23 May 2022, from https://patientsafetymovement.org/patient-safety/the-facts/ The Pharmaceutical Journal, PJ, February 2019, Vol 302, No 7922;302(7922):DOI:10.1211/PJ.2019.20206204 Rodziewicz TL, Houseman B, Hipskind JE. Medical Error Reduction and Prevention. [Updated 2022 Jan 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/

References (continued…) Schwappach, D. L. B., Taxis, K., & Pfeiffer, Y. (2018). Oncology nurses‘ beliefs and attitudes towards the double-check of chemotherapy medications: A cross-sectional survey study. BMC Health Services Research, 18 doi:https://doi.org/10.1186/s12913-018-2937-9 The Pharmaceutical Journal, PJ, February 2019, Vol 302, No 7922;302(7922):DOI:10.1211/PJ.2019.20206204 Tompkins McMahon, J. (2017). Improving Medication Administration Safety in the Clinical Environment. MEDSURG Nursing , 26 (6), 374–409. U.S. National Library of Medicine. (n.d.). New treatments for addiction: Behavioral, ethical, legal, and social questions. National Center for Biotechnology Information. Retrieved May 3, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK24638/? qk=1

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