Medication Administration, Errors And Prevention

MEDICATION ADMINISTRATION, ERRORS AND PREVENTION Missouri Assisted Living Association

THE BIG PICTURE • Medications are probably the single most important health care technology to prevent illness, disability and death. • Medications can: – Control symptoms of chronic disease. – Prevent complications of disease. – Improve quality of life. – Improve functional status.

“Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.” Sir Cyril Chantler, Former Dean, Guy’s, King, and St. Thomas’s Medical and Dental School, Lancet 1999

“Any symptom in an elderly patient should be considered a drug side effect until proven otherwise.”

Gurwitz J, Monane M, Monane S, Avorn J. Long-Term Care Quality Letter, Brown University. 1995 TAKING MEDICATIONS SERIOUSLY HOW SERIOUS IS THE PROBLEM?

Medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States.

http:www.fda.gov/cder/drug/MedErrors HOW BIG IS THE PROBLEM? • At least 1.5 million preventable medication errors occur each year. • A hospital patient can expect to be subjected to more than 1 medication error each day.

IOM Report Brief July 2006; www.iom.edu/object.File/Master/35/943/medication%20errors%20new.pdf MEDICATION ADMINISTRATION • Medication administration to residents may be the most critical function of a nurse/med tech. • The nurse/med tech MUST follow the Policies and Procedures of the facility. MEDICATION ADMINISTRATION - GENERAL CONSIDERATIONS • Sustained-release and enteric coated medications CANNOT be crushed. • Liquid suspensions and emulsions should be shaken well before being administered. • Liquid medications should be measured properly – at the BOTTOM of the meniscus. MEDICATION ADMINISTRATION - GENERAL CONSIDERATIONS • Each med cart or MAR book should have a list of medications NOT to be crushed. • Each med cart or MAR book should have a metric-apothecary conversion chart. • Medication directions on the label should correspond to the directions on the MAR – or contain a “Direction Change – Check MAR” sticker. MEDICATION ADMINISTRATION TECHNIQUE - PATCHES • Check for the correct timing of the patch. – Daily, Q 72 H, Twice weekly, Weekly, etc. • Be sure to remove the old patch BEFORE applying a new patch. • Wash and dry the skin area to assure that it is not excessively oily, dirty, raw, chapped, or irritated. MEDICATION ADMINISTRATION TECHNIQUE - OPTHALMICS • Suspensions should be shaken gently. • Position patient with head back. • Use gauze to GENTLY pull down lower lid to form a “pouch”, instructing the patient to look up. • Instill required number of drops (or a thin line of ointment) inside the lower lid, close to outer corner of eye. MEDICATION ADMINISTRATION TECHNIQUE - OPTHALMICS • Patient should close eye slowly and refrain from blinking, keeping eye closed for 1-2 minutes. • Allow 5 minutes between different eye drops. • Remember that eye drops may be used in the ear, BUT EAR DROPS CANNOT BE USED IN THE EYE! MEDICATION ADMINISTRATION TECHNIQUE - OTICS • Position patient with ear up. • Straighten ear canal be GENTLY pulling the ear lobe up and backward. • Instill the prescribed dose into ear canal. • Have the patient lie with the ear up for 5 minutes after administration. MEDICATION ADMINISTRATION TECHNIQUE – MDIs (INHALERS) • Spacing and proper sequence of different Metered Dose Inhalers is very important!!! • If patient uses more than one MDI, follow this sequence: – Bronchodilators/beta-agonists – Anticholinergic Agents – Corticorsteroids MEDICATION ADMINISTRATION TECHNIQUE – MDIs (INHALERS) • Hold inhaler upright. • Shake well. • Take a deep breath and exhale completely. • Position inhaler in mouth, close lips around inhaler. • Press down on inhaler to release medication as you breathe in slowly. MEDICATION ADMINISTRATION TECHNIQUE – MDIs (INHALERS) • Breathe in slowly – over 3 to 5 seconds. • Hold breath for 10 seconds to allow medication to reach deeply into lungs. • Wait 1 minute between puffs!!! • Wait at least 5 minutes between different inhalers!!! MEDICATION ADMINISTRATION TECHNIQUE – MDIs (INHALERS) • Obtain an order for a spacer device if the patient has trouble with coordinating MDI, trouble deep breathing, dislikes the taste, or has trouble with coughing. • Patient should rinse mouth with water after using steroid inhalers. • Store inhalers separate from eye drops. MEDICATION ERRORS Medication errors can occur anywhere in the distribution system: – Prescribing – Repackaging – Dispensing – Administering – Monitoring MEDICATION ERRORS Common causes of medication errors include: – Poor communication – Ambiguities in product names, directions for use, medical abbreviations or writing – Poor procedures or techniques – Patient misuse because of poor understanding of the directions for use of the product DEFINITION OF MEDICATION ERROR The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP), an independent body comprised of 25 national and international organizations, defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.” MEDICATION ERRORS • Sharp End – Error investigations always concentrate on sharp end (active front line staff) where patient/caregiver interaction occurs. • Blunt End – Contributing factors and blunt end (latent) errors often originate where organizational policies, procedures and resource allocation decisions are made. WHY ARE SENIORS AT RISK? HOW MEDICATION ERRORS AFFECT THE ELDERLY The Elderly: – Generally take more medications than the young, so they are at a greater risk of taking the wrong medication or taking the right medication in the wrong dosage – Are more sensitive to the effects of medication due to physiologic changes and may not be able to tolerate usual adult dosages HOW MEDICATION ERRORS AFFECT THE ELDERLY The Elderly: – Use more OTC medications than younger people, thus increasing the risk of incompatibilities of medications or overdoses – May suffer from cognitive impairment, making following administration and dosage instructions difficult and dangerous – May experience vision problems, making reading directions difficult, increasing the risk of error HOW MEDICATION ERRORS AFFECT THE ELDERLY

Physiologic changes related to the aging process compound the risks the elderly already face when taking medications. HOW MEDICATION ERRORS AFFECT THE ELDERLY General Physiologic Changes: – Increased percentage of body fat – Decreased cardiac output – Decreased kidney and liver function – Decreased plasma albumin

Result: Because of these changes, a decrease in the dose of some medications may be needed to optimize benefits and avoid toxicity and adverse reactions. HOW MEDICATION ERRORS AFFECT THE ELDERLY Physiologic Changes and Drug Absorption: – Decreased stomach acid and intestinal blood flow – Decreased stomach emptying time

Result: Because of these changes, there may be a decrease in the rate of drug absorption, causing a delay of action and peak effectiveness HOW MEDICATION ERRORS AFFECT THE ELDERLY Physiologic Changes and Drug Distribution: – Changes in body composition – Reduced lean muscle mass which results in an increased ratio of fat to muscle – Reduced cardiac output

Result: Because of physiologic changes in the body, the distribution of drugs may change. HOW MEDICATION ERRORS AFFECT THE ELDERLY Physiologic Changes and Drug Metabolism: – Decreased liver blood flow, liver size and enzyme activity, which affect the ability of the liver to breakdown (metabolize) drugs.

Result: Because of the decrease in liver function, it may be necessary to reduce the dose of medications metabolized by the liver. HOW MEDICATION ERRORS AFFECT THE ELDERLY Physiologic Changes and Drug Elimination: – Decrease in kidney blood flow and drug receptor site(s) causing more (or less) sensitivity to a drug effect. Result: Because of the decrease in kidney function, it may be necessary to reduce the dose of medications removed by the kidneys. FACTORS CONTRIBUTING TO MEDICATION ERRORS The American Hospital Association (AHA) lists the following factors as common causes of medication errors: • Incomplete resident information. For example, not knowing about a resident’s allergies, other medications, previous diagnoses, and lab results. FACTORS CONTRIBUTING TO MEDICATION ERRORS • Unavailable drug information. For example, lack of up-to-date warnings of how a particular drug may interact with food or other drugs. • Miscommunication of drug orders. For example, poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations. FACTORS CONTRIBUTING TO MEDICATION ERRORS 4. Lack of appropriate labeling. For example, when a drug is prepared and repackaged into smaller units. • Environmental factors. For example, lighting, heat, noise, and interruptions can distract the healthcare worker during drug administration.

Nordenberg T. FDA Consumer 2000, Sep-Oct. 34(5) WHO IS TO BLAME? THE SYSTEM!!! – Medication errors are NOT attributable to individual healthcare workers. – But rather to the breakdown of a complex healthcare system. – The Institute of Medicine (IOM) clearly states that the medication errors are the result of a series of failures in the medication management system. WHO IS TO BLAME? • Medication errors are a property of the system as a whole rather than results of the acts or omissions of the people in the system!

• Performance improvement requires changing the system, NOT changing the people! WHO IS TO BLAME? IT’S A BAD SYSTEM!!! Consider: – Physician calls order to nurse – Nurse writes down order, faxes to pharmacy – Order not correct or unclear, pharmacy calls nurse – Nurse calls physician – Physician clarifies order – Nurse writes down order, faxes pharmacy WHERE DO THESE ERRORS OCCUR? • Assessing the resident’s medical needs – Missed symptoms • Selecting the appropriate medication for the resident – Confusing drugs that look alike or sound alike • Writing and ordering the prescription – Dose miscalculations – Unclear orders – Poor handwriting – Confusing use of abbreviations and symbols – “Confirmation Bias” CONFIRMATION BIAS • Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in waht oredr the ltteers in a word are, the olny iprmoent tihng is that the frist and lsat ltteer be at the rghit pclae. • The rset can be a tatol mses and you can still raed it wouthit a porbelm. • Ths is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as a wlohe. TYPES OF MEDICATION ERRORS The following eight categories of medication-related errors have been identified:

• Untreated indication • The resident requires medication but is not receiving the medication. • Improper drug selection • The resident requires medication but is receiving the wrong medication. TYPES OF MEDICATION ERRORS • Sub-therapeutic dosage • The resident is being treated with an inadequate dose of the correct medication. • Over dosage • The resident is being treated with too much of the correct drug. • Adverse drug reaction • The resident has a medical problem as a result of an unintended and detrimental adverse drug reaction. TYPES OF MEDICATION ERRORS 6. Drug interaction • The resident has a medical problem as a result of an interaction between medications or food. • Failure to receive drugs • The resident has a medical problem as a result of not receiving the proper medication. • Drug use without indication • The resident is taking a medication without a valid medical reason. THE SIX RIGHTS • Right drug • Right dose • Right resident • Right time • Right route • Right documentation THE SIX RIGHTS • Right Drug – Know the generic and the brand name of the drug – Know why the drug is ordered – Have a current drug reference available • Right Dose – Make sure dosage symbols are clear and match on MAR and the container – If a medication is a different color or shape, check with the pharmacist – Have another qualified person check calculations THE SIX RIGHTS • Right Resident – Use 2 unique identifiers – Never leave a drug at a resident’s bedside unless the resident has an order to self- administer • Right Time – The right time is considered one hour before or after the scheduled time except for specific drugs (before and after meals) and/or as ordered (sliding scale insulin) THE SIX RIGHTS • Right Route – The physician’s order must designate the correct route.

• Right Documentation – PRN orders. – Refused orders. – Injectable orders. – Patches. – A dose is not considered given until it is charted as such. JCAHO AND MEDICATION ABBREVIATIONS JCAHO AND MEDICATION ABBREVIATIONS JCAHO AND MEDICATION ABBREVIATIONS JCAHO AND MEDICATION ABBREVIATIONS WHY SO MANY ERRORS? • Healthcare is distinct in its complexity A resident is the recipient of numerous activities performed each day that rely on the interaction of monitoring, treatment, and support systems. • Healthcare is decentralized and fragmented The prescribing and delivery of medications requires the completion of at least five interdependent steps: ordering, transcribing, dispensing, delivering, and administering. Within any of these steps are opportunities for error. WHY SO MANY ERRORS? • Organizational factors Healthcare is provided in a variety of settings. • Nature of errors Medical errors usually affect only a single patient at a time and are therefore treated as isolated incidents. COMMON MEDICATION ERRORS • Wrong eye/ear. • Wrong strength. • Wrong quantity. • Wrong dosage form. • Wrong drug. • Wrong time. • Failure to shake well. • Failure to ‘mix’ insulin. • Improper eye drop technique. • Improper MDI technique. • Allowing residents to swallow SL tablets. TWENTY-FOUR TIPS FOR REDUCING ERRORS • Be an active, cooperative member of the healthcare team. • Always read the drug packaging label three times during dose preparation. • Write legibly. • Do not guess at anything. If an order is difficult to read, ask for clarification. TWENTY-FOUR TIPS FOR REDUCING ERRORS • If workload is unusually heavy, speak with the charge nurse or supervisor. • Correctly identify the resident before administering medications. • Monitor residents for possible adverse drug reactions (ADRs). • Slow down. Rushing nearly always results in errors. TWENTY-FOUR TIPS FOR REDUCING ERRORS • Clearly write all orders with a ballpoint pen. Print the name of the drug. • Avoid the use of abbreviations for drug names. • Avoid the use of unnecessary symbols on medication orders. • Include the indication for the medication for each order. For example, “for hypertension.” TWENTY-FOUR TIPS FOR REDUCING ERRORS • Before administering any unfamiliar medication, refer to a reference or contact the pharmacist. • If the situation requires a telephone order, repeat the order back for verification. • Maintain only authorized (stock) medications on the nursing unit. • Return all discontinued medications promptly to the DON for destruction. TWENTY-FOUR TIPS FOR REDUCING ERRORS • Always use a leading zero to precede a decimal point when dosages are less than 1. Never use a trailing zero. For example, 0.25mg. • Complete a Medication Error Form for all errors. • Trend all reports and discuss in the QI or QA committee meetings. • Implement annual in-services on medication error prevention. TWENTY-FOUR TIPS FOR REDUCING ERRORS • Keep medication preparation areas orderly, well lit, and free of clutter, distraction and noise. • Standardize methods of labeling, packaging, and storing medications. • Identify all “high alert” drugs in use and utilize standard procedures in their use. • Dispense medication in unit-dose form whenever possible. PREVENTING MEDICATION ERRORS THERE IS NOT ONE SIMPLE SOLUTION!!! The following areas need to be further explored as ways to prevent medication errors. • Accurate reporting systems and a determination of what type of errors should require mandatory reporting. • Promoting a Culture of Safety. PREVENTING MEDICATION ERRORS 3. Computerized systems • Distribution • Labeling • Laboratory and x-ray reports • Medical record exchange • Prescribing • Storage A CULTURE OF SAFETY

Promoting a culture of safety means that the healthcare industry must stop “blaming” individuals, take an objective look at what happened and look for possible solutions. The end result is a healthier and safer environment for residents and patients. A CULTURE OF SAFETY

A non-punitive, system-based approach to error reduction does not diminish accountability. It redefines accountability and directs it in a productive and useful manner. A CULTURE OF SAFETY • Determine why the error occurred • Prevent recurrence, do not assign blame • Use science: obtain facts and be thorough • Identify weak points in the system • Establish methodologies to address existing problems • Use agreed upon methodologies • Evaluate and revise as necessary A CULTURE OF SAFETY • Emphasize safety versus assigning blame. • Encouraging co-workers to voice observed problems in a constructive manner. • Learning from each other. WHY AREN’T WE USING AVAILABLE TECHNOLOGIES? • The physician’s reluctance to learn and use. • The unavailability of convenient hardware and medication software. • The cost of technology. It is important to note that using technology will not solve all the problems. It is, however, one of many necessary interventions to ensure the safety of our patients. ARE YOUR PHYSICIANS READY FOR CPOE? MANY “SOLUTIONS” FOR SALE “ANSWERS” ARE OFTEN WORSE THAN THE PROBLEM SUMMARY • Medication errors are a serious problem. • Primarily due to the fragmented nature of our healthcare industry. • Many steps in process, each of which leads to opportunities for error. • Understanding why and finding ways to prevent future errors is critical to the safety of our patients. • Ongoing training should be a part of orientation and skill competency evaluations. A SIGN OF THE TIMES?