30. Where in the Process do Medication Errors Occur? Reference: http://www.ahrq.gov
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43. Unintended Medication Discrepancies at the Time of Hospital Admission 6% Severe harm potential 61% No harm potential 33% Moderate harm potential More than half of patient have 1 unintended medication discrepancy at hospital admission Reference: http://www.ahrq.gov
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Editor's Notes
5 rights-refer to medication administration policy if needed Communication with family/patient is essential. They are a line of defense. Example: If you inform them of their medications prior to administration and they question a particular drug, don ’t ignore them. Red flag! High risk medications include:TPA, Amphotericin,Neuromuscular blockers, Chemotherapy, sedation, analgesia, anesthetic agents, insulin ,Phenytoin, potassium, TPN,Lipids, & investigational drugs. Refer to specific policy if needed Proper storage includes recommendations to limit or eliminate floor stocks. Avoid “mini pharmacies”. Do not store similar sounding drugs near each other. Error occurred with mix-up of hydralazine being administered instead of hydroxyzine. Label all substances found at the bedside. Label syringes at the time of preparation of meds.
Training/competency assessment: Following established protocols and procedures. Orientation process, personal responsibility for education, in-services, ongoing competency evaluations. Specific types of systems have been found to improve the overall medication use process. Automated dispensing devices or units can effectively decrease med errors by eliminating multi-dose concentrations of drugs and the need for reconstitution. They can decrease errors of omission by increasing the availability of meds. Good for stat & first doses. They are not fail proof. Example: If the sleeve where a specific drug should be was filled with the wrong drug and the nurse does not check it an error can occur. NOTE: Eventually all medication orders will be checked by a pharmacist before the drug can be removed from the Pyxis system. Computerized order entry systems in which the prescriber generates a medication order via the computer decreases med errors at the ordering and prescribing stages. Systems check the drugs indication against a diagnosis, patient allergies, drug interactions, lab tests, acceptable doses etc. In order to be effective these systems must interface with the pharmacies system. Overall these systems effectively reduce errors relating to the prescribing and transcribing process. JHS will be moving to this type of system.
Computerized MARS - Have significantly decreased errors related to transcription. There is one set of documents for pharmacy, the point of dispensing, nursing and the point of administration. Bar coding technology is another option. When the patient is admitted they are assigned a bar code. The staff has a scanner and any deviations sound alarm. This can decrease some types of medication errors such as the wrong patient. A drawback to this method is the cost. There are several studies that note the presence of clinical pharmacists greatly reduces error. One study in JAMA 99 noted adverse drug events decreased by 66% when a clinical pharmacist was placed in an ICU.
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