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Preventing Errors Related to
Drug Administration
Learning Objectives
• Identify sources of errors related to drug
administration
• Discuss prevention strategies to decrease
the potential for drug administration errors
• Explain the role of interdisciplinary
personnel in preventing drug
administration errors
Preventing Drug Administration Errors
Nurses perform important functions that support safe
medication use:
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Document medication administration
Assess the patient’s response to medications and notify
prescribers
Educate patients and families about medication use
Depending on the institution and existing automation, nurses also
may:
• Obtain and document the patient’s medication history
• Reconcile medications prescribed upon admission, transfer,
and discharge
• Transmit orders to the pharmacy
• Transcribe orders and verify orders on the medication
administration record (MAR)
Preventing Drug Administration Errors
All members of the health care team involved in choosing the
patients’ drug therapy, evaluating orders, and preparing
medication must work together to ensure that the systems in
place support safe medication use
Obtaining Patient Information
Safe administration of medication requires accurate
information
• Patient Identification
• Age, weight, and height
– Use one standard unit of measurement, preferably kilograms
– Establish a standard routine for reweighing patients
– When weight is critical, be sure it is accurate; be clear about the
source of a patient’s weight (e.g., measured, calculated, reported,
estimated)
– Height also may be a critical measurement particularly in pediatrics
• Diagnoses
– Some error types are less likely if practitioners know a patient’s
diagnoses
– The nurse can match patients’ medication to their diagnoses and
ensure that each drug’s intended purpose makes sense
• Pregnancy and lactation status
– Some drugs are teratogenic, causing fetal harm in utero
– Many drugs transfer into breast milk and some pose a risk for the infant
Obtaining Patient Information
Allergies
– Drugs that cause severe allergic responses include antibiotics, opioids,
NSAIDs, vaccines, and insulin
• The nurse should ask patient to describe the type of allergic reaction
previously experienced
• True allergies, intolerances, and sensitivities are all generally reported as
“allergies”
– An allergy may be missed when a drug contains two or more medications
(e.g., Vicodin contains hydrocodone and acetaminophen)
– OTC medications and herbal supplements should be included in
patient information because they may cause allergic reactions
– Latex allergies: some rubber stoppers on vials contain latex
– Document allergies prominently on the patient’s MAR and in a
standard location on the patient’s medical record
Obtaining Patient Information
Current Medications
• It can be difficult to get a complete list of medications,
vitamins, nonprescription drugs, and herbals that the newly
admitted patient uses
– Patients may not accurately report all of their medications and
dosages
– Patients may not want to report the use of home remedies or herbals
– Past medical records may not be up-to-date
• Other pharmacies or doctors’ offices may need to be
contacted to get accurate patient medication information
• The Joint Commission (TJC) now has a National Patient
Safety Goal (NPSG) that requires hospitals to reconcile
patient medications at each step in the inpatient health care
process
– At intake, at transfer within and outside the facility, and at discharge
– Applies to inpatient and outpatient admissions
– See www.jointcommission.org for up-to-date information
Identifying the Patient
• Possibility of medications being administered to the wrong patient
can start in any phase of the medication-use process
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Physician orders a medication for the wrong patient
Secretary or nurse transcribes the order onto the wrong patient’s MAR
Pharmacist enters a medication into the wrong patient’s profile
Nurse gives a patient’s medication to another patient
• Reading the patient’s armband and as a spoken affirmation of the
patient’s name are necessary (“What is your name?” and not “Is
your name John Doe?”)
• In 2004, TJC began requiring use of two unique identifiers (e.g.,
name, birth date, identification number) when taking blood
samples, or when administering medications or blood products
• Patient’s MAR should be taken to the beside for the required
verification of patient identifiers
– Point-of-care bar code systems, which scan the patient identification
bracelet and the drug for verification, help confirm accurate delivery
Monitoring the Patient
• Nurses and caregivers must continually evaluate the effects of
medications on the patient to ensure safety and efficacy
• When trating patients with pain, both pain management and safety
are high priority
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Insufficient monitoring can lead to oversedation
Evaluate pain scores after each dose
Evaluate respiratory rate, depth, and quality
Consider cumulative narcotic dose (e.g., both intra- and postoperative doses in post-anesthesia care unit [PCAU])
• When assessing need for a therapeutic change, consider
therapeutic goal, patient input, and safety
• Lab and diagnostic results can guide medication selection
and dose modification as well as signal that medication is
contraindicated
– Plotting dose administrations on a flow sheet along with key
laboratory values is a useful technique for monitoring medication
therapy
Drug and Dosing Guidelines
• Nurses need ready access to reliable information
– Typical dose and route of administration for a new medication
recently added to the formulary
– IV compatibility
– Typical doses, in milligrams per kilogram, for pediatric patients
– IV / PO dose conversion chart for opioids
– Acceptable infusion rates for medications (e.g., heparin)
– Whether a medication can be crushed for administration
Drug and Dosing Guidelines
• Nurses need access to current drug information references
– Books, electronic databases, textbook, or reliable Internet source
– Must be up to date (discard outdated material)
– Information needs include: incompatibilities, adverse events, changes
in drug administration policy, and addition of new products
• At a minimum, provide references for:
– Drugs and herbals
– Dosing guidelines
• Dosing charts
– Adverse drug reactions and drug interactions
Drug and Dosing Guidelines
• No more than two
– Nurse should question a single dose composed of more than two
dosage units
• Pharmacist can often formulate several tablets or capsules into a single
dose, making it easier for the patient to swallow
• Same principle applies to preparation of IV solutions
• Change in dose with change in route
– Because of potential differences in bioavailability and drug
distribution, verify the dose when route of administration is changed
• Examples: levothyroxine, opioid analgesics, and hydromorphone
Drug and Dosing Guidelines
• Drugs expressed as a ratio or percentage
– Most injectable medications expressed in mg/mL or mcg/mL
– Many drugs used for resuscitation expressed as percentages or
dilution ratios
• Dose conversion chart for all concentrations of drugs used for
emergencies should be posted on code carts
• If possible, have only one concentration available; bold warning labels
should be affixed to alert staff if different concentrations are available
• Liposomal products
– Some medications available as conventional and liposomal
formulations; dosages are not interchangeable
• Examples: Amphocin, Fungizone, and Adriamycin
– Store and dispense by the pharmacy only
– Encourage physicians to include the brand name when prescribing
liposomal products
• List both brand name and generic on MARs, as well as “liposomal form”
• Independent double check before administering is advisable
Communicating Drug Information
Accurately
• Errors can originate in either of the two places nurses get
information about the drugs they administer:
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MAR
Original medication order
• Problems arise from these sources:
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Order or prescription
Order transcription
MAR
Documenting administration
Communicating orders to the pharmacy
Communication barriers
The Order or Prescription
Written Orders
– Most medication orders are handwritten using lined no-carbon
(NCR) order forms
– Lines on the order form help legibility, but may obscure part of
the writing
• 7 may appear to be a 1 or a decimal point or other mark is not
seen
• 0.5 mg may appear to be 5 mg if the physician fails to put the zero
and the decimal is obscured on the line; 1.0 mg may appear to be
10 mg
– Eliminate the lines from the back copy of the NCR form to help
prevent errors
• Add a zero before a decimal point and eliminate trailing zeros
– Only the original should be used to fax or scan
– Clinicians should not try to interpret marginally legible orders
• When in doubt, call for clarification!
The Order or Prescription
Error-Prone Abbreviations
• Poorly communicated drug information can lead to errors
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Error-prone dose expressions
Abbreviations
Acronyms
Coined names
Symbols
Use of incorrect drug names
Confusing expressions of dosage forms
• TJC forbids using certain ambiguous expressions and
abbreviations (see Chapter 8 on error-prone abbreviations
and dose expressions)
The Order or Prescription
Incomplete Orders
• Question any unclear or potentially ambiguous order before
administering a medication
• Following package directions may not be the way a physician wants the
medication administered
Verbal Orders
• Orders spoken aloud whether in person or over the phone, can easily be
misunderstood
• Only the prescriber can verify that the recipient heard the message
correctly
• Incomplete verbal orders may result in the nurse filling in presumed
information which may be incorrect
• Since 2003, TJC has required this procedure:
1) Nurse transcribes verbal order onto patient’s record as received
2) Nurse reads back (not repeats back) the complete transcribed order
to the prescriber, repeating each digit in the dosage separately (e.g.,
five-zero rather than 50)
Order Transcription
• Transcription of spoken or written orders can result in errors
• Using computerized prescriber order entry (CPOE) eliminates
traditional order transcription
• Precautions providers should take when transcribing spoken
orders
– Avoid numbered orders
• Order number may be misinterpreted as part of the dose
• If numbering is necessary, circle each digit so the number is not written as
part of the dose
– Always list the dose after the drug name on transcribed orders, not
before it
– Stray marks (e.g., initials, letters, or check marks) can obscure or
change the look of a medication order
• Table 11-1 in the textbook addresses safety strategies for
accepting and transcribing spoken orders
Order Transcription
• Written orders received by pharmacists and nurses should
be uncluttered and clear
• Necessary notations that are not part of the drug and dosage
should be made at the bottom of the page
– Notations written on the bottom are less likely to obscure the drug
dose or drug name
• A separate column or box should be included on the form if
notations or check marks are needed to track complete
transcription within order sets
Medication Administration Records
• MARs can be in several forms:
– Handwritten
– Computer print-out
– Displayed on an electronic screen
• Ways errors occur on handwritten MARs:
– Writing is crowded or illegible
– Information is presented in an inconsistent manner
• Orders are transcribed onto the MAR exactly as written
– Presentation of information may not be consistent
– Error-prone abbreviations or dose expressions may be carried onto
the MAR
– Allergies and other information may not be present on a handwritten
MAR
• A medication prescribed and transcribed using brand name
but dispensed as a generic may cause confusion
Medication Administration Records
• Benefits of computer-generated MARs for preventing errors
– New, changed, or discontinued orders appear on the MAR in “real
time” awaiting verification by the pharmacist and nurse
– Brand and generic names of the product listed
– Consistency (e.g., spelling, dose documentation)
– Enables the nurse to compare his/her transcription with the
pharmacist’s
– Provides consistent drug messages, warnings, and information on
patient allergies, current diagnoses, and chronic conditions
Medication Administration Records
Ideally, MAR would list:
– First line: drug name (generic with brand in parentheses)
– Second line: patient-specific dose, route, and frequency (and
indication, if applicable) in bold print
– Third line: product strength, special instructions, or warnings
Medication Administration Records
• If oral liquids must be dispensed in multidose bottles, the
container’s total volume should not be listed on the MAR
• Interdisciplinary meetings to identify and prioritize MAR
format problems can help to ensure the presentation of
medication orders is clear to nurses
– Essential for information system staff to attend so they can work with
the software vendor to make changes
• MARs that are too long can lead to inadvertent omissions
– Long MARs may be the result of preprinted order sheets
– Medications need to be standardized among the various preprinted
order forms
– All contingencies do not need to be covered on preprinted orders
– MARs with too many pages need to be identified and addressed
• Clinicians can work on preprinted orders to minimize the
variety of prescribed medications, routes of administration,
and dosages
Documenting Administration
• The medication must be recorded on the MAR immediately after it
has been administered, not before administration to patient
– Recording too early and then not giving the medication could result in
patient receiving no medication
– Recording patients’ doses later and not completing the task could result
in duplicate medication
• Dose administration documentation should be in a portion of the
record designated only for that purpose
– Do not document dose administration within the narrative notes
– Some drugs, like insulin, have extra space for recording monitoring
variables, however these records should not be kept separately in the
chart because the MAR will be incomplete
– Alert prescribers when the patient refuses a dose
– Follow-up should take place when an unadministered dose is
returned to the pharmacy with no explanation for the reason (although
this is a good idea, it is often not feasible)
Communicating Orders to the Pharmacy
If CPOE Is Not in Place
• A fax or scanned image is often sent to the pharmacy by unit
secretaries
• The pharmacy staff may make regular rounds to the nursing units to
pick up copies of the orders in some institutions
• Orders may be sent via pneumatic tube to the pharmacy
Send All Orders
• All orders should be sent to the pharmacy
• Pharmacists need to be aware of all information regarding
the patient:
– Tests and procedures, dietary status, planned discharge
• Total record of the patient helps pharmacist critically assess
each medication order
• Voice mail or other message systems are not appropriate to
communicate orders because there is no reading back of
the transcription
• A faxed copy of the actual order may be a safer method
Communicating Orders to the Pharmacy
Causes of Obscured or Illegible Transmissions
• Roller of a fax or the glass surface of a scanner must be
cleaned regularly and well maintained when they are used
to send medical orders or prescriptions
• Line noise during transmission, dust, dirt, stuck paper,
correction fluid, and hole punches
• Stickers affixed but not removed before transmission
• Prescribers sometimes write to the edge of the document
and the scanner or fax does not “read” the whole order
causing part of it to be lost
• Figure 11-2 in the textbook shows an example of an order
that was read incorrectly because of a poor image
transmission
Communicating Orders to the Pharmacy
Admissions From Emergency Department (ED)
• Pharmacists may not be dispensing all medications
administered to patients in hospital EDs because the nurse
does not send the order to the pharmacy for medications
that are available as floor stock
• Staff must communicate all the drug therapy that has been
prescribed and administered if the patient is admitted
• Profile should include drugs from the ED so drugs
prescribed upon admission can be compared and screened
against the medications used in the ED
• For updated requirements regarding ED dispensing and
administering, see www.jointcommission.org
Communicating Orders to the Pharmacy
Admissions From ED (continued)
• A particularly harmful duplicate therapy from the ED
includes the use of heparin
– Patients’ current and recent MARs should be reviewed before any
heparin product is administered to prevent unintended duplicate
therapy
• Helpful reminders on the order forms and heparin protocols:
– Discontinue low molecular weight heparin (LMWH)
– List time interval (8 to 24 hours) before heparin therapy can be
started if a patient has received a dose of LMWH
• ED nurse should mention and clearly document all doses of
LMWH administered when the patient is transferred to an
inpatient setting
Communicating Orders to the Pharmacy
Communication Barriers
• The hierarchical structure in health care organizations may
make it uncomfortable or difficult for nurses and other health
care professionals to share concerns or voice opinions
about the safety of an order
• Review Chapter 23 in the textbook for strategies to
overcome intimidation and improve communication for
managing medication risks
Drug Labeling, Packaging, and
Nomenclature
• Picking up a container and thinking it is a different product is
easy to do because packaging is similar with some products
• Table 11-2 gives some safety strategies for look-alike and
sound-alike drug names
– Affix “name alert” stickers to areas where look-alike products are
stored
– Accept spoken orders only when truly necessary
– Circle important information on the package to draw attention to
differences
– Segregate medications with look-alike packages by storing in
separate areas
– Create alerts to appear on the screen of automated dispensing
cabinets (ADCs) for medications in look-alike packages
Additional Information on the
Role of Drug Names and
Drug Packaging and Labeling
in Medication Errors
Available in Slide Deck for
Chapters 6 and 7
Drug Labeling, Packaging, and
Nomenclature
Syringes
• Errors can occur when a nurse with an unlabeled syringe
intends to use it immediately but gets interrupted and puts it
down unlabeled
– A syringe of medication or solution must be labeled if it leaves the
hand of the person filling it and will not be administered immediately
– A syringe prepared anywhere other than at the bedside for immediate
use must be labeled
• Use commercially prepared labels, restock labels often, and
do not use tape to label syringes
Drug Labeling, Packaging, and
Nomenclature
Medications on a Sterile Field
• Findings of a 2000 self-assessment by participating
hospitals
– 25% reported full labeling
– 24% did not label anything
• Findings of 2004 ISMP Medication Safety Self Assessment
(1,600 hospitals)
– 41% reported always labeling containers used on a sterile field
– 18% reported not labeling any solutions or medications on the sterile
field
• Only a slight improvement in this basic safety measure is
surprising
• The requirement for labeling in inpatient and outpatient
settings was the subject of an NPSG in 2006 by TJC see
www.jointcommission for full details
Drug Labeling, Packaging, and
Nomenclature
Labeling to the Point of Administration
• Do not open or remove medications from unit dose packages
until the point of administration
• Medications are difficult to identify once removed from
packaging
– Unlabeled medications should not be returned
– Increased risk of mixing up medications once the packaging is
removed
• Taking medications for multiple patients into a patient’s room
increases the chance the a patient will get the wrong
medication
Drug Storage and Standardization
Storing Drugs on Patient Care Units
• Safety checks are bypassed when products are available for
administration prior to a pharmacist check (e.g., floor stock not in an
ADC)
• Problems can occur when the pharmacist does not screen patientspecific doses before administration of the drug
– Excessive doses, duplicate therapy, drug allergies not detected
Unit Dose Distribution
• Credentialing agencies such as TJC recognize unit dose distribution
as the standard of practice for inpatient settings
– Reduces the need for floor stock in patient care areas
• Many drugs are received in bulk and need to be repackaged
• Methods that reduce errors when repackaging should be employed
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Chemicals
– Some chemicals, (e.g., Hemoccult Sensa, Seracult) routinely by
nurses have been mistaken for eye drops
– Never leave these types of products in bedside stands, medicine
carts, patient bathrooms, or anywhere they could be mistaken for
medications by nurses, patients, or family members
– Never pour chemicals used for any purpose into saline, medication, or
water containers, even if labeled clearly
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Concentrated electrolytes
– Access to undiluted electrolytes should be restricted or eliminated
– TJC requires the removal of concentrated electrolytes (e.g.,
potassium chloride) from patient care units because they have been
mistakenly given without the proper dilution, resulting in death
– Similar dangers are still posed by other concentrated electrolyte
solutions (e.g., sodium chloride >0.9%)
– Treatments for cases requiring electrolytes, such as severe
hyponatremia, can be started with typical concentrations of sodium
chloride until the needed concentration can be prepared by the
pharmacy or the premixed solution can be dispensed
– Review chapter 14 in the textbook for additional cautionary
information about electrolytes and other high-alert medications
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Concentrated morphine oral solution
– Available at both 20 mg/5mL and 20 mg/mL creating potential for
confusion
– Some physicians prescribe in mL instead of mg, causing errors when
multiple concentrations available
• Orders without a specified dose in mg should not be accepted
– Pharmacy should dispense concentrated oral morphine solutions in
unit dose oral syringes for specific inpatients rather than having floor
stock in patient care unit
– Unused supplies should be returned to the pharmacy immediately
after the patient is discharged
– The wrong strength of concentrated product could be stocked or
removed by mistake, therefore ADCs alone will not prevent errors
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Concentrated insulin
– Some patients with insulin resistance are prescribed concentrated
insulin (500 units/mL or U-500) rather than U-100 insulin
– U-500 Humulin R has a red label that warns “high potency” and “not
for ordinary use,” but the type size is small and easily overlooked
• Documented mix-ups include a nurse taking U-500 from the refrigerator
and administering it as U-100, resulting in a fivefold overdose
• U-500 was on the patient care unit because it had been previously
prescribed for a patient who had since been discharged
– Ideally, pharmacy should dispense the dose in a syringe when the
insulin is prescribed for a specific patient
– U-500 should never be given IV because of the potential danger from
an overdose
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Sterile water
– A lack of knowledge about the hazards of IV administration of sterile
solution have resulted in serious patient harm and death
• Physician prescribed “free water” IV at 100 mL/hour for an elderly patient
with congestive heart failure, hyperglycemia, and severe hypernatremia
• Free water is water not associated with organic or inorganic ions
• Free water can be given orally but never by IV as plain sterile water
without additives to increase osmolarity
• The physician had called the pharmacy and asked if large bags of sterile
water for injection were available and the answer was yes
• The 2 L bag of sterile water was sent to the ICU after the order was
received and the nurse began the infusion without question because she
had overheard the physician’s question to the pharmacy
• The nurse missed the red statement on the bag: “Pharmacy Bulk
Package, Not for Direct Infusion” because the label was on the opposite
side of the bag and another warning against using the product for IV
injection without first being made approximately isotonic was obscure in
text
• The error was caught by another nurse and the IV stopped, but the
patient subsequently died of renal failure
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Sterile water (continued)
– Establishing a protocol for severe hypernatremia can avoid
this type of error
– Pharmacists should use 2 L containers or larger of sterile
water in the pharmacy for preparing solutions, making it more
apparent to nurses if the larger bag was dispensed mistakenly
– Bags of sterile water have been mistaken for look-alike bags
of IV solution when inadvertently stocked on patient care units
– The Malignant Hyperthermia Association recommends that 1 L
bags of sterile water for use in diluting Dantrium be stocked in
the hyperthermia boxes in ORs and PACUs
– Unused or partially used bags of the sterile water solution may
get into IV stock or be hung as IV solution during emergencies
causing a concern for hospitals
– Errors can be prevented by replacing 1 L sterile water bags
with 50 mL vials
Drug Storage and Standardization
Hazardous Drugs and Solutions in Floor Stock
• Neuromuscular blocking agents
– Deaths reported when neuromuscular blocking agents were
removed from the refrigerator and mistakenly administered to
patients who were not mechanically ventilated; errors caused by:
• Similar packaging
• An inexperienced nurse medicates an agitated patient with the agent that a
physician failed to discontinue after extubation
– These drugs should be stocked only in critical care units, the ED,
and the OR
– Neuromuscular drugs should be stored in zip-lock bags with the
following warning label affixed: “WARNING: Paralyzing agent”
– Neuromuscular drugs should be completely separated from other
stock, preferably in a closed box in the refrigerator
Drug Storage and Standardization
Multidose Vials
• The use of multidose vials (MDV) is a cost saving measure
that should be reexamined
– Contamination of the MDV can quickly erode the cost-saving factor
– Practitioners may decide that more of the solution is needed for the
patient, use the same needle and syringe, and contamination occurs
– Single-dose vials of anesthetics contain no preservatives to prevent
microbial growth, therefore they should not be reused after initial
entry
• Use prefilled syringes, either purchased or filled by the
pharmacy, instead of vials for heparin flushes, saline, and
bacteriostatic water
– Pharmacy should dispense labeled vials for each individual patient if
MDV must be used
– Keep the vial with the patient’s medications and discard upon
discharge
– Store and discard MDVs according to manufacturers’
recommendations
– MDVs that are used but undated should be discarded
Drug Storage and Standardization
Flammable Products
• Each year about 100 surgical fires occur with outcomes that
can be devastating
• Some of these fires are a result of flammable medications
in the form of ointments, wound dressings, skin preparation
agents, and eye lubricants
• Flammable benzoin sprayed on an operative incision
ignited when a physician decided to cauterize a bleed after
he had nearly finished suturing an eye
• Highly flammable products, such as ethyl chloride, can be
ignited with even a static discharge
• Often, safer alternatives are available; the need for the use
of a flammable product should be evaluated
Drug Storage and Standardization
Missing Medications
• A missing medication dose can be a sign of a potential error
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Medication was given but not documented
Medication was given in a procedure area or on another unit
Medication was ordered by brand name but dispensed as a generic
Therapeutic interchange occurred
Medication frequency or time was not correctly scheduled
Order was incorrectly interpreted or transcribed, or not sent to the pharmacy
Pharmacy did not dispense the medication because of a safety problem (e.g.
unsafe dose)
– A discontinued drug remains active on the MAR
• Missing doses could be related to system problems with pharmacy
dispensing and delivery
• The original order should be verified before a missing medication is
requested and administered
• Never borrow a dose from other patients’ supplies even if it causes
a delay in treatment
Drug Storage and Standardization
Nurse Preparation of IV Solutions
• Procedures for preparing a drug infusion are:
– Assemble correct drug with correct volume and solution of diluent
– Calculate and measure how much drug to add to the solution
– Mix the solution and prepare an accurate label
• Work space is often cramped counter in the nursing unit,
likely with distractions and interruptions during the process
– No independent double-check system
– Not conducive to safe drug preparation
– Using pharmacy-prepared or commercially available admixtures is
much safer and simpler
– Pharmacy should prepare and dispense injectable solutions not
commercially available
• Rarely should a nurse mix and hang a solution immediately
– Another nurse should independently verify the calculations and
preparation if pharmacy is closed or in emergency situation
Drug Storage and Standardization
Nurse Access to Pharmacy
• TJC does not allow nurses to have access to the pharmacy;
also some states prohibit after-hours access; for complete rules
concerning after-hours access, go to www.jointcommission.org
• Many errors linked to nonpharmacists retrieving the wrong
medication, dose, dosage form, strength, vial, or concentration
from the pharmacy
– A nursing supervisor opened a pharmacy and tried to determine the
contents of 15 mL vials of potassium phosphate injection
– The information on the label was overwhelming, but the supervisor
believed that 15 mM and 15 mEq were equal, so she dispensed two
vials that were mixed and added to the IV fluid of a patient by another
nurse
– The supervisor documented two vials at 15 mM, but left a 15 mL vial
as a sample; thus, the error was detected when the pharmacy
reopened within the hour
Drug Storage and Standardization
Nurse Access to Pharmacy (continued)
• What to do when pharmacy services are not available:
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Use an outside pharmacy
Have floor stock in ADCs
Have floor stock in nonautomated dispensing cabinets
If state laws and regulations allow, give access to a location
containing selected medications
– A night formulary with a limited supply of specific medications could
be stocked in a centralized dispensing cabinet
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•
Stock with premixed IV solutions
Stock with unit dose medications
Nonformulary drugs should not be available
Minimize the number of vials or doses
• Night drug cabinet policies help prevent errors
• Centralized order processing systems help prevent errors
Environment, Workflow, and Staffing Patterns
Distractions
• During 1998–2002, nearly 35,000 distraction-related errors
were report to USP’s MEDMARX database; nurses were the
largest category of personnel involved in these errors
– 11% of prescribing errors
– 12% of administration errors
– 73% of transcription errors
• Distractions doubled the rate of “wrong patient” errors
• Nurses are subjected to many distractions that may interfere
with tasks involved with drug administration
• Inadequate staffing for a given workload coupled with ringing
telephones and requests for information are common
problems during transcription and entry of orders
• Poorly designed work processes contribute to the likelihood
of errors
Environment, Workflow, and Staffing Patterns
Staffing Level
• A 2003 IOM report concluded that nurses work in an
environment that fosters errors, not safety
• Medical-surgical nurses were found to be responsible for 6
patients daily with 23% of hospitals reporting as many as 12
patients
• Nurse staffing patterns should:
– Provide elasticity in each shift to accommodate unpredictable
variations in patient volume, acuity, and workload
– Let nursing unit staff regulate unit workflow and determine
criteria for unit closures as their workload and staff dictate
– Continually evaluate the effectiveness of staffing practices
• ICUs should have one licensed nurse for every two patients
• Long-stay residents in nursing homes should have:
– One RN for every 32 patients (0.75 hour per resident day)
– One licensed nurse for every18 patients (1.3 hours per resident day)
– One nursing assistant for every 8.5 patients (2.8 hours per resident day)
Environment, Workflow, and Staffing Patterns
Staffing Level (continued)
• Nursing home staffing regulations are not in line with current
safe staffing practices (e.g., regardless of patient capacity,
requirement is one RN for 8 consecutive hours daily)
– Most of the care in nursing homes is provided by nursing assistants,
with federal regulations specifying no minimum staffing levels
• The 2003 IOM report found that changes in nurse staffing
patterns are needed to improve patient safety
– Patient volume estimates should count admissions, discharges, and
less than full-day patients as well as patients at a point in time
– Direct care nursing staff should help select and evaluate the methods
used to determine the appropriate unit staffing for each shift
Environment, Workflow, and Staffing Patterns
Long Hours and Overtime
• Long work hours and fatigue of health care providers pose
serious threat to the safety of the patients
• A health care provider who has been awake for 24 hours has
the cognitive functioning of someone who is legally drunk
• According to the 2003 IOM report, nurses should work no
more than 12 hours a day and 60 hours a week (including
scheduled shifts and overtime)
• See Reducing Fatigue in the Workplace on page 267 of the
textbook for further fatigue fighting recommendations
Environment, Workflow, and Staffing Patterns
Workflow and Workload
• Timing of medication administration
– Usually within 60 minutes of the scheduled time is the defined time
frame for medications to be administered
– Unit dose systems have improved the timeliness of administration
because of the reduced preparation time
– More medications are administered in the morning than at other
times, therefore the potential for error is greatest in the morning
– Medications such as warfarin are given in the late afternoon or at
bedtime allowing for laboratory monitoring before administration
– Timing of each medication has to be considered in relation to other
medications the patient is receiving
– Drug incompatibilities or interactions should be noted when the
medications are ordered and added to the MAR
– Nurses and pharmacists should work together to determine the
appropriate administration schedule
Environment, Workflow, and Staffing Patterns
Workflow and Workload (continued)
• Standard administration schedules should be determined by
the facility
– Delayed, omitted, or duplicate doses are a result of:
•
•
•
•
Nonstandard times
Delayed therapy
Forgetting to administer the drug
Nurses not accustomed to administering drugs at nonstandard
times
• Duplicate drug administeration (at the conventional time and
again at the nonstandard time)
• Dosing windows
– Nurse needs an agreed-upon way to convert subsequent doses to
the standardized schedule when a first dose is given at a
nonstandard time
– Many hospitals have guidelines for these “dosing windows”
Environment, Workflow, and Staffing Patterns
Workflow and Workload
• Dosing windows
– This matrix of staggered dosing times provides a guideline for
determining when to safely administer the second dose based on
when the first does was administered
– By the third dose, patients are generally back on schedule
– Dosing windows give consistent guidelines to both nurses and
pharmacists to help ensure that a schedule is followed
– Exceptions have to be made for drugs that require individualized
pharmacy scheduling based on the time of the first dose
– Changes in schedules may result when a patient requires a
procedure or to avoid simultaneous administration of incompatible
drugs
– The dosing window matrix is a helpful way to keep communication
open between pharmacists and nurses
Staff Competency and Education
• All health care providers require education on a continuing basis,
whether they are new or seasoned veterans
• Competency is improved by having timely access to information
about proper use of medications
• Recommendations for nurses in the 2006 IOM report, Preventing
Medication Errors, include:
– Make a safe work environment for medication preparation,
administration, and documentation
– Commit to safety principles in medication administration
– Question drug orders and evaluate patient responses confidently with
improved team training and communication
– Strive to improve the systems that address near misses
– Help to evaluate the efficacy of new safety systems and technology
– Contribute to development and implementation of error reporting
systems and support the reporting of medication errors
Patient Education
• Errors can be prevented when patients are encouraged to
ask questions and get answers about their medications
• 2003 ISMP survey of nurses on teaching patients about their
medications
– 94% most often talked to their patients at discharge
– 84% most often talked to their patients during drug
administration
– One-quarter never provide written information
• One-third felt the written material did not provide clear information
• One-quarter said lack of written materials about medications was
a frequent problem
• One-third said multilingual material access was difficult
• One-quarter found the materials were not written on a level their
patients could easily understand because of reading level or
health literacy
Patient Education
• 2003 ISMP survey of nurses on teaching patients about
their medications (continued)
―68% require all patients to repeat information or demonstrate
techniques they were taught
– 75% in teaching hospitals required repeating of information or
demonstration of techniques
– 80% gave patients a way to contact them with questions after
discharge
– 56% in teaching hospitals had little or no written information to
give patients about prevention of medication errors
– 41% in nonteaching hospitals had little or no written
information to give to patients about prevention of medication
errors
– Table 11-5 in the textbook gives tips for teaching patients
about using their medications
Quality Processes and Risk Management
• Unlike prescribing errors that may be intercepted by the
pharmacist or nurse, medication errors originating during the
medication administration process are likely to reach the
patient
• More than 50% of the medications that cause harm begin
with drug administration
• Double-check systems for medication administration are
necessary to prevent potentially harmful errors by detection
and correction before the patient receives the drug
– Interdisciplinary double-check system
– Independent double checks
– Automated double-check systems
Interdisciplinary Double-Check Systems
• Having more than one practitioner between the drug and the
patient is the ideal medication administration system
– A pharmacist may find a prescribing order that includes an
inappropriate dose, duplicate therapy, or drug interaction
– A nurse may find a pharmacy dispensing error while checking before
administration
– A physician may be checking the daily printout of the patient’s
current medications and find a drug has been discontinued
inadvertently by a nurse or the pharmacy
• A system for double-checking medications is present in
most pharmacies
• Safety is compromised when drugs are borrowed from other
patients, obtained from the ADC prior to pharmacists’
screening, or prepared by nurses from floor stock
Interdisciplinary Double-Check Systems
• Unit dose system is utilized in most hospitals
• Nurse and pharmacist can separately verify each dose
before it is sent to the unit or administered
• The pharmacist checks the MAR, finds the dose does not
correspond, and is alerted to some error
– Misinterpretation or mistranscription
– Incorrect medication may have been chosen
• Examples showing utility of double checking
– A float nurse misread the MAR, prepared a PHENobarbital IV not in
the bin, and administered the drug, never calling the pharmacy
• The dose was not missing, the patient was supposed to receive
PENTobarbital and the pharmacist could have clarified
– An order for Rocephin was misinterpreted by the unit secretary and
not questioned by the nurse; the order was put in as qid rather than
q12
• The pharmacist caught the error or the patient would have gotten twice
the amount of prescribed medication
Independent Double Checks
• Two nurses working separately can independently verify
each other’s work, thereby creating a suitable double check
– One prepares the dose while another independently checks the
order, makes calculations, and they compare
– KEY = working separately, not encouraging and helping each other
to the same outcome
– Person requesting the double check should not influence the checker
• Nurses double checking is not always accepted because:
– The time is not justified for the small benefit
– More mistakes happen because the checkers rely on each other
– Staff shortages; even with double checks errors can still happen
• Errors occur if illegible orders are misread by both nurses
• Limit double checks to high-alert drugs, complex processes,
and high-risk patients
• A process that prevents errors is better than one that detects
them
Automated Double-Check Systems
• Bar code scanning at the point of care is useful for
verification
• Bar coding cannot yet confirm the correct programming of
an infusion pump
– This technology is in the pipeline and being tested currently
• “Smart” infusion pumps incorporate safe dosage ranges and
accurate programming
• Smart pumps cannot verify the correct connections on the
pump
• Keep manual checks for the most critical areas and work to
design effective double-check systems
Reference
Smetzer JL, Cohen MR. Preventing drug administration
errors. In: Cohen MR, ed. Medication Errors. 2nd ed.
Washington, DC: American Pharmacists Association; 2007.