Medication Errors
The observed or identified preparation or administration of medications/biological not in accordance with MD order, manufacturers specification, accepted professional standards and principles with providing services according to state specific regulations.
What is a medication error?
1. Cause significant health complication with the resident.
2. Missed work for staff/family member.
3. Excess undo worry about the resident.
How can a medication error impact a resident/family/staff?
1. Eight rights of medication administration
2. Double check process with transcription
3. At least 2 resident identifiers.
4. Avoiding interruptions with med pass.
How can we prevent medication errors?
1. Resident Name
2. Resident picture
3. Resident DOB
4. Asking another seasoned staff member.
What are possible resident identifiers during medication administration?
While doing this, you are to sign the medication out of the MAR and document in the Narcotic book (as applicable to medication given).
What is Administering medication
1. Similar Drug names and resident names
2. Expired Meds
3. Overdose or under-dose
4. Omission or wrong route
5. Wrong resident
6. Documentation omission
What are common medication errors?
770,000 of patient's are injured annually because of these
What are medication errors?
This person reviews medications monthly to determine unnecessary drugs. This information they provide must be acted on by the DON and the Medical Director and documented in a separate written report on what actions were taken.
Who is the pharmacist?
Studies have shown that this takes 1/3 of a nurse's time during a work day.
What is medication administration?
You document this in the MAR after checking the resident's blood glucose level at the specified times.
What is blood sugar reading, units of insulin given, and administration site.
Calculating the percentage of med errors observed during a medication administration observation. Numerator= # of errors and Denominator= # of opportunities for error.
What is the medication error rate?
In the event of a medication error, these people will be notified (hint: its multiple parties!)
MD, Family (POA), Supervisor
Any drug used in excessive use, excessive duration, without adequate monitoring and indications for use and/or in presence of adverse consequences which indicate the dose should be reduced or discontinued.
What are unnecessary drugs?
While administering narcotics, we must document administration in the MAR and sign the drug out of this:
What is the Narcotic Book?
When giving pain medication, you must also fill out and complete this tool to monitor pain level, location, and effectiveness.
What is the Pain monitoring tool and/or pain management flow sheet
This is a medication error that causes discomfort or jeopardizes his/her health and safety.
What is a significant medication error?
This is ranked as the 6th highest cause of mortality
MEDICATION ERRORS = ~100,000
This is when the facility must ensure that residents who have not sued psychotropic drugs are not given unless the medication in necessary to treat a specific condition as diagnosis and documentation in the clinical record indicates. This will occur unless clinically contraindicated.
What is a GDR?
This must be completed each time the narcotic keys are surrendered from one liscensed staff to another.
What is narcotic count?
We have this long before and after the scheduled time for a medication to be given within compliance.
What is 1 hour before and 1 hour after!
We are to obtain hold orders from this person when appropriate during medication administration.
Who is the MD?
This is the tag received when medication error rates are 5% or greater.
What is a F759 tag? (OIG)
1. Right medication
2. Right dose
3. Right time
4. Right resident
5. Right route
6. Right documentation
7. Right response
8. Right reason
What are the 8 rights of medication administration?
If patient refuses/is unable to take the dose or if a dose is dropped or otherwise rendered unable to administer we must do this.
What is destroying the drugs with 2 licensed nurses.
These are to be locked when the nurse steps away or it is not in the nurse's line of site.