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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Frequent Types of Drug Errors
• Administering improper dose
• Giving wrong drug
• Using wrong route of administration
Pharmacology for Nurses: A Pathophysiologic Approach, Third Edition
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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.
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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
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Copyright ©2011 by Pearson Education, Inc.
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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
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Copyright ©2011 by Pearson Education, Inc.
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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.
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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.
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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.
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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.