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Pharmacology for Nurses A Pathophysiologic Approach Third Edition CHAPTER 9 Medication Errors and Risk Reduction Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 1 Each nurse is responsible for becoming familiar with the nurse practice acts of the state in which he or she practices because these acts: Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 1 – Choices 1. Protect the nurse from malpractice suits 2. Contain national standards and responsibilities 3. Contain job descriptions for all nurses 4. Define nursing practice and standards of care for the nurse practicing in a specific state Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 1 – Answer 1. Protect the nurse from malpractice suits 2. Contain national standards and responsibilities 3. Contain job descriptions for all nurses 4. Define nursing practice and standards of care for the nurse practicing in a specific state Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 1 – Rationale Rationale: Nurse practice acts encompass all aspects of nursing, including the definition of professional nursing, medication administration, and definition of standards of care. Cognitive Level: Analysis Nursing Process: Implementation Patient Need: Safe, Effective Care Environment Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 2 The nurse administers a medication to the wrong patient. The appropriate nursing action is to: Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 2 – Choices 1. Monitor the patient for adverse reaction before reporting the incident 2. Document the error if the patient has an adverse reaction 3. Report the error to the physician, document the medication in the patient record, and complete a report of the error for further followup and analysis 4. Notify the physician and document the error in a report only Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 2 – Answer 1. Monitor the patient for adverse reaction before reporting the incident 2. Document the error if the patient has an adverse reaction 3. Report the error to the physician, document the medication in the patient record, and complete a report of the error for further follow-up and analysis 4. Notify the physician and document the error in a report only Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 2 – Rationale Rationale: The nurse is responsible for documenting medication errors and completing an incident report for review by the facility’s quality assurance personnel. Cognitive Level: Analysis Nursing Process: Implementation Patient Need: Safe, Effective Care Environment Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 3 The patient with liver dysfunction experiences toxicity to a drug following administration of several doses. This adverse reaction may have been prevented if the nurse had followed which phase of the nursing process? Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 3 – Choices 1. 2. 3. 4. Assessment Planning Implementation Evaluation Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 3 – Answer 1. 2. 3. 4. Assessment Planning Implementation Evaluation Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 3 – Rationale Rationale: Prior to administering medications, the nurse should assess renal and liver function and impairments of other body systems that may affect pharmacotherapy. This is especially important when administering medications to elderly and severely debilitated patients. Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 3 – Rationale (cont'd) Cognitive Level: Analysis Nursing Process: Assessment Patient Need: Physiological Integrity Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 4 Nurses have a legal and moral responsibility to report medication errors. The steps of reporting these errors include: Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 4 – Choices 1. Punishing the nurse who committed the error 2. Monitoring unsafe medication orders 3. Identifying potential unsafe medication facilities 4. Examining interdisciplinary causes of errors and assisting professionals in ways to avoid mistakes Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 4 – Answer 1. Punishing the nurse who committed the error 2. Monitoring unsafe medication orders 3. Identifying potential unsafe medication facilities 4. Examining interdisciplinary causes of errors and assisting professionals in ways to avoid mistakes Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 4 – Rationale Rationale: The Food and Drug Administration (FDA) and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) encourage nurses and other health care professionals to report medication errors. This aids in examining interdisciplinary causes of medication errors and developing methods to prevent them, thereby promoting medication safety. Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 4 – Rationale (cont'd) Cognitive Level: Analysis Nursing Process: Implementation Patient Need: Safe, Effective Care Environment Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 6 When the nurse enters the patient’s room with a medication, the patient states “I’m on the phone, just leave my pill on the table there.” What would be the best response by the nurse? Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 6 – Choices 1. Leave the pill at the bedside as requested 2. Ask the patient to let the nurse know when the phone call is completed so that the nurse can return with the medication 3. Instruct the patient to either take the medication or refuse it 4. Chart the medication as “unable to give” and skip the dose Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 6 – Answer 1. Leave the pill at the bedside as requested 2. Ask the patient to let the nurse know when the phone call is completed so that the nurse can return with the medication 3. Instruct the patient to either take the medication or refuse it 4. Chart the medication as “unable to give” and skip the dose Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 6 – Rationale Rationale: This approach best ensures a collaboration between the nurse and patient, allows the nurse to ensure the medication is taken, and provides an opportunity for the nurse to teach the patient about the medication. Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. NCLEX-RN Review Question 6 – Rationale (cont'd) Cognitive Level: Application Nursing Process: Implementation Patient Need: Safe, Effective Care Environment Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medication Error Defined • Any error that occurs in medication administration process, whether or not it harms the patient. May be applied to – Misinterpretations, miscalculations – Misadministration – Handwriting misinterpretation – Misunderstanding of verbal orders • Medication Index - classifies medication errors (Figure 9.1) Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Factors That Contribute to Medication Errors by the Health-Care Provider • Omitting one of the rights of drug administration • Failing to perform an agency system check • Failing to take into account for patient variables such as age, body size, and renal or hepatic function Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Factors That Contribute to Medication Errors by the Health-Care Provider (cont'd) • Giving medications based on verbal orders or phone orders • Giving medication based on an incomplete order or an illegible order • Practicing under stressful work conditions Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Factors That Contribute to Medication Errors by the Client • Taking drugs prescribed by several practitioners • Getting prescriptions filled at more than one pharmacy • Not filling or refilling prescriptions Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Factors That Contribute to Medication Errors by the Client (cont'd) • Taking medications incorrectly • Taking medications that may be left over from a previous illness • Taking medications prescribed for something else Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Impact of Medication Errors • Common cause of morbidity and preventable death in hospitals • Emotionally devastating to nurse and client • Increased cost to patient and facility, as it may extend client’s stay Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Impact of Medication Errors (cont'd) • Poor reputation for unit or facility, caused by high incidence of errors • Penalizing of administrative staff because of errors Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Investigating Errors • No acceptable rate of medication errors • Errors should be investigated and subjected to analysis to determine causes Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reporting and Documenting Medication Errors • Documentation should occur in a factual manner • Documentation in medical record must include specific nursing interventions that were implemented following error in order to protect client Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reporting and Documenting Medication Errors (cont'd) • Document all individuals who were notified of error • Medication-administration record (MAR) is a source detailing what medication was given or omitted Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reporting with an Incident Report • Details recorded in factual and objective manner • Allows nurse to identify factors that contributed to the error • Is not part of client’s hospital record • Used by agency’s risk management personnel for quality improvement Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Legality and Reducing Errors • Accurate documentation verifies client’s safety • Used as tool to improve drug administration processes • Reduction of medication errors can be created from written data – Root cause analysis (RCA) - seeks to prevent another occurrence by asking what happened and why, and what can be done to prevent it Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Sentinel Events • Unexpected occurrences involving death or serious physical or psychological injury, or risk thereof • Always investigated • Interventions taken to ensure there is no repeat Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Assessment • Assess food or medication allergies • Assess current health concerns • Assess use of OTCs and herbal supplements • Review recent laboratory tests Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Assessment (cont'd) • Review recent physical-assessment findings • Identify need for education of medication regimen Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Planning • Avoid using abbreviations that can be misunderstood • Question unclear orders • Do not accept verbal orders Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Planning (cont'd) • Follow specific facility policies and procedures related to medication administration • Ask to client to participate by restating the right time and dose of medication Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Implementation • Be aware of potential distractions during medication administration • Remove distractions, if possible • Focus on task of administering medications • Practice the rights of medication administration Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Implementation (cont'd) • Keep in mind the following steps – Positively verify patient using name and birthdate – Use correct procedures for all routes of administration – Calculate medication doses correctly – Open medications prior to administering – Record on MAR immediately after administering Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Implementation (cont'd) • Keep in mind the following steps – Confirm patient has swallowed medication – Be alert for long-acting oral dosage forms with indicators such as LA, XL, and XR Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Reduction of Medication Errors and Incidents—Evaluation • Assess client for expected outcomes • Determine if any adverse effects have occurred Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Nurses and Errors • Nurses should know most frequent types of drug errors and severities of reaction • Nurse should never administer a medication unless familiar with uses and side effects – PDAs now help with this Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Frequent Types of Drug Errors • Administering improper dose • Giving wrong drug • Using wrong route of administration Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Severities • One-half of fatal medication errors occurred in clients older than 60 years of age • Children are another vulnerable population due to smaller dosages Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medication Reconciliation • The process of “keeping track” of a patient’s medications as they proceed from one health care provider to another • Polypharmacy - patients to receive multiple prescriptions that have conflicting pharmacologic actions Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Medication Reconciliation (cont'd) • Many serious medication errors tracked to poor reconciliation • Reconciliation lists all medications a patient is taking to reduce errors • Hospitals encouraged to document complete list when patient is admitted Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Educate Client with • Written, age-appropriate handouts • Audiovisual teaching aids • Contact information Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Additional Client Education • • • • Know names of all medications Know what side effects may occur Use appropriate administration devices Read label prior to each drug administration • Carry list of all medications, including OTC and herbals • Ask questions Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Methods to Reduce Number of Medication Errors • Automated, computerized, locked cabinets for medication storage on client-care units • Risk-management departments to examine risks and minimize the number of medication errors • Collaboration with nursing to modify policies and procedures Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Examples of Beneficial Policies and Procedures • • • • • Correctly storing medication Reading drug label Avoid drug transfer between containers Avoid overstocking to prevent expiration Monitor compliance with current medication abbreviations • Removing outdated reference books Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved. Governmental and Other Agencies that Track Medication Errors • FDA’s MedWatch – Health care providers encouraged to report errors – Errors may be reported anonymously • Institute for Safe Medication Practices (ISMP) • MEDMARX - U.S. Pharmacopeia’s anonymous medication error reporting program Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition Adams • Holland Copyright ©2011 by Pearson Education, Inc. All rights reserved.
