Reducing Medication Errors In The LTC Setting - PHCA

Susan M Cleveland BSN, RN, WCC, CDPDirector of Nursing Services for Institutional Care PharmacyTiffin and Mason, OH; Sharpsville, PA

List some common medication errors and associated regulatory deficiencies. Identifying administrative supports for a successful medication pass. Describe the pharmacist role in reducing medication errors. Discuss medication administration processes to prevent errors.

An error occurs when the preparation or administration of adrug is not done in accordance with: Physician’s orders Manufacturer’s specifications Accepted professional standards and principles

Causes discomfort or jeopardizes safety of the resident Guidelines for determining Significance Resident Condition Drug Category Frequency of Error

Illegible handwriting Transition related Similar packaging or labeling Incorrect selection from a computerized product list “Confirmation Bias” Addition of Suffixes Transcription errors to the MAR

Lack of knowledge of the drug Lack of Patient Information Violation of the rules Faulty Identity Checking Infusion Pump / Parenteral delivery problems Inadequate monitoring Drug Stocking & Delivery problems Preparation Errors

Accupril Accutane AlprazolamLorazepamCardene Cardura Flomax Fosamax Lamisil Lomotil Nizoral Neoral Plendil Prilosec Zantac Zyrtec USP Quality ute of Safe Medication mes.pdf

F157F164F241F272F279F281F309F323F325F328 Notification of change Privacy/Confidentiality DignityComprehensive assessment Comprehensive care plan Professional standards Quality of care Accidents/supervision Acceptable parameters Special needsF329 Unnecessary drugsF332/333 Med errorsF371 Sanitary conditionsF385 Physician servicesF425 Pharmacy servicesF431 Storage of drugs/biologicalsF441 Infection ControlF501 Medical directorF524 Clinical recordsF516 Confidentiality/Safety ofrecords

Handwriting Lack of specificity EMR related errors Failure to review Failing to identify the symptoms the new Lack of physician-physician handoff communication Covering physicians order medications

Delivery issuesExpired medications in E-box, refrigeratorDispensing errors Medication Dose Failure to identify issues: Laboratory monitoringDrug-drug interactionsAllergiesDuplicate categories of medications

Frequent Distractions/Care Changes Communication between disciplines Failure to identify medication diversion Inadequate attention to the role of the nurse Lack of support/resources/supervision Pharmacy provider does not include medication pass observations

Failure to follow “rights” Failure to assess vital signs Failure to monitor laboratory Failure to assess resident’s condition Dose omissions, “holds,” crushing

Tracking and reporting systems Foster positive relationships Establish interruption priorities Establish universal cart set-up Provide adequate tools and training

Establish a list of medications not needed after hospitalization Do not accept “continue previous orders” Reconcile medications Verify admission orders Request information early Provide feedback to hospital

Reduce polypharmacy Ensure proper monitoring Medication scheduling Trend errors Education Medication reconciliation

Pre-admission med list Write accurate admission orders Reconcile all variances Provide continuing support and maintenance

Verbal orders Enunciate slowly and distinctly State numbers like pilots Spell out difficult drug names Specify concentrationsCohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

U TIW Ug D/C Q.D. DC Q.O.D HS SC cc SQ AU, AS, ADError Prone Abbreviation List: pdf

Placing a zero after a decimal point example 1.0 mg correct 1 mgPlacing no zero before decimal dose example .5 mgcorrect 0.5 mg

Review MAR Prepare medications Do not borrow Inspect medication for expiration date and/or contamination Compliance with Nursing Standards

5 Rights of Medication Administration: Right Drug Right Dose Right Route Right Patient Right Time

60 minutes before or after scheduled time Before meals is up to15-30 minutes before meals With meals can be up to 30 minutes after After meals is usually up to 60 minutes after

Stay with the resident and monitor for: Desired therapeutic effect of the medication, Lack of evidence of therapeutic effect, Side effects, adverse drug reactions, especially those severe enough to stopthe medication and allergic reactions.

Antipsychotics Anticoagulants Diuretics Antiepileptic

Never touch Do not crush list Glove use Mixing parameters Sublingual or buccal

Shake medication well Pour into graduated cup Pour away from label Never pour back into the bottle Rinse viscous liquids

Store separately Wash hand with soap and water after administration More than one drop preparation given 5 minutes apart Avoid touching dropper to mucus membrane Shake suspensions before administration

Handwashing and glove application Remember privacy rights prior to exposing the tube Check placement of NG or G-Tube prior to giving meds Flush enteral feeding tube before and after meds given

Wear gloves Drape resident Inspect skin Shake lotions/sprays Apply dressings Reposition Proper disposal Handwashing

Shake MDI’s well, and position correctly Wait 1 minute before giving next puff of MDI Wait 5 minutes between puffs or as ordered Rinse mouthpiece and wash hands

Mix Insulin correctly Pens – scrub the hub Storage and dating Multi-use equipment

Provide adequate fluids with medications To administer specific medications with food and antacids Computers may help decrease the risk of confirmation bias. Software alert pharmacists during the prescription adjudicationprocess. Administer medications that are properly labeled. Know the appropriate storage requirements. Apply ongoing patient monitoring for effects.

Be knowledgeable about medication indications, precautions, contraindications,expected outcomes Administer medications that are properly labeled Know the appropriate storage requirements of medications Apply ongoing patient monitoring for desired/undesired effects of medication Clarify incomplete, illegible, or any order of concern Have knowledge of medication administration devices Have adequate access to patient information (history, allergies, prognosis)

Universal cart set-up throughout building Cart set up prior to pass Food and beverages dated, labeled, closed container Only authorized staff members have access to keys Have cart in direct line of vision

Bar coding labels Minimizing drug name confusion Drug labeling Error tracking and public education

1.Institute for Safe Medication Practices. http://www.ismp.org/default.asp. (Accessed March 3, 2017).2.Institute for Safe Medication Practices. List of error-prone abbreviations, symbols, and dosedesignations. 2015. pdf. (Accessed March 3,2017).3.Institute for Safe Medication Practices. Accessed March 3, 2017)4.Institute for Safe Medication Practices. Residents vulnerable to harmful medication errors duringtransition from hospital to long term care facility. ssues/LTC201307.pdf. (Accessed march 31, 2017).5.Stefanacci, Richard G DO, MGH, MBA, AGSF, CMD. Preventing medication errors. Managed HealthCareConnect. 2006 ALTC (updated 2009)6.Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

List some common medication errors and associated regulatory deficiencies. Identifying administrative supports for a successful medication pass. Describe the pharmacist role in reducing medication errors. Discuss medication administration processes to prevent errors.