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Quarterly Medication Error Data January 2006 Quarterly Error Report Medication Error data based upon Safety Reports No report = No data Greater than 51% of RN’s report they have made a medication error in the past 12 months.* Only 5% of significant errors are reported. * Reports are completed* Error is life-threatening Medication Vital to Patient’s Treatment *Lowe, Debra K and Belchre, Jan V. 2002. Reporting medication Errors Through Computerized Medication Administration. CIN: Computers, Informatics Nursing. 20:5. 178-183. Error Stage for Serious Medication Errors Administer Ordering 38% 39% eMAR OE Dispensing 11% Transcription 12% Leape, JAMA 1995 Quarterly Error Report 10/2005 – 12/2005 Ordering: 20 (11%) Dispensing: 10 (5.5%) Administration: 144 (83%) Total: 174 Ordering Dispensing Administration Emerging Themes eMAR System only as good as the user that drives it. Team double-checks not being performed Physician and Nurse check patients’ allergies Pharmacist default Times of First Dose not verified / corrected Time of Next Dose not verified By passing Reconciliation Prompt Not documenting pain medication administrations Top Nine Wrong Frequency 60 51 Pump Programming 50 Ordering 40 Wrong Dose 24 30 20 20 Wrong Med 17 10 20 10 8 Dispensing 5 4 Other No allergy order 0 1st Qtr Communication Medication Errors Two nurses double-checked red syringe of chemotherapy then placed syringe in refrigerator. Nurse came back and retrieved red syringe from refrigerator and administered med to patient. Patient received wrong drug. Medication Error Medication order written for Toradol with instructions not to give the med until 10pm. Instructions not read by nurse. Patient received Toradol against instructions. Two incidences Medication Errors Patient ordered for Fentanyl 0 – 100 mcg / hour continuous infusion. Flow sheet indicated patient received 2.5 mL/hr = 25 mcg/hr. Pump programmed for 25 mL/hr = 250 mcg/hr. Patient bradycardic Medication Error Bypassed verification of medication removed from Omnicell. Nurse intended to retrieve Haldol from Omnicell. Medication Error Ommicell drawer contains both Haldol and Lasix. Removed Lasix from drawer. Administered wrong medication (Lasix) to patient IVP. Questions? Please email Carol Luppi [email protected]