m edication e rrors : a n i nterdisciplinary a pproach
DESCRIPTION
G OALS : 1. Define medication error 2. Identify types of medication errors 3. Identify strategies to reduce medication errorsTRANSCRIPT
MEDICATION ERRORS: AN INTERDISCIPLINARY APPROACH
ROBERTA MCINTYRE, MSN, RNNursing Service ConsultantOffice of Developmental ProgramsWestern Region
GOALS: 1. Define medication error
2. Identify types of medication errors
3. Identify strategies to reduce medication errors
DEFINITION: Any wrongful or incorrect administration of a
medication
Any preventable event that may lead to inappropriate medication use or patient harm
A failure in the treatment process that does or has the potential to lead to patient harm
KEYS TO PREVENTION: Report all near misses and med errors
Turn drug administration into a protected time
Do not be afraid to question anything you suspect is not correct
THE FIVE RIGHTS Right person
Right medication
Right dose
Right route
Right time
THREE GOALS OF MEDICATION ADMINISTRATION: 1. Reduce or eliminate the possibility of an
error
2. Make errors visible before they reach the patient
3. Minimize the consequence of an error if it does reach the patient
ABBREVIATIONS AND SYMBOLS
QUALITY PROCESS AND RISK MANAGEMENT Make it difficult for staff to make an error
Promote detection and correct errors before reaching the patient and causing harm
METHODS TO INVESTIGATE ERRORS
DEBRIEFING PROCESS 1. Approach Staff
2. Ask staff
3. Ask staff
ACHIEVED OBJECTIVES Agency intent
One on one time with staff
Uncover additional issues
Staff ownership
DEBRIEFING GOALS 1. Prevent or minimize future occurrences
2. Decrease the harm of future med errors
3. Identify systemic problems
4. Identify need for change
HCSIS REPORTING SYSTEM
WHY REPORT ERRORS Potential risks
Actual errors
Cause of errors
Prevention
WHAT TO REPORT Risk
Near misses
Errors, no harm
Errors, harm
INFORMATIVE REPORTS INCLUDE: HOW
WHY
SUGGESTIONS
HCSIS SYSTEM WHY
WHAT
AGENCY RESPONSE
ANY QUESTIONS?
CONTACT INFORMATION Roberta McIntyre, MSN, RN Nursing Service Consultant ODP – Western Region 301 Fifth Avenue Suite 490 Piatt Place Pittsburgh, PA 15222 [email protected]