Preventing and reporting drug administration errors

16 August, 2005
Any nurse who has made a drug error knows how stressful this situation can be. Registered nurses are accountable for their actions and omissions when administering any medicines and must take responsibility for any errors they make. ABSTRACT VOL: 101, ISSUE: 33, PAGE NO: 32 Chloe Copping, RGN, is practice nurse, Buckden Surgery, Cambridgeshire Any nurse who has made a drug error knows how stressful this situation can be. Registered nurses are accountable for their actions and omissions when administering any medicines and must take responsibility for any errors they make.

However, the increasing demands placed on nurses can render them more prone to drug errors. Overwork can affect concentration and competence and this can be exacerbated by erratic working hours and stress, while complacency can also lead to mistakes (Parish, 2003). While nurse fatigue is a commonly cited cause of drug errors, others include illegible physicians handwri ting and distractions (Mayo and Duncan, 2004).

In its guidelines for the administration of medicines, the NMC (2004) outlines the information a prescription must contain for safe and correct drug administration and gives clear principles for prescribing medicines (Box 1). If the prescription is clear and accurate, errors are less likely to occur.

Health care providers have a responsibility to identify and minimise high-risk areas or conditions, which include those where paediatric medicines are calculated and administered, and clinical areas that use large quantities of controlled drugs (Smith, 2004).

Defining a drug error There is a range of opinion about what constitutes a drug error (OShea, 1999) and nurses, pharmacists and doctors may not actually agree on what the precise definition is.

The National Patient Safety Agency uses the definition of the US National Coordinating Council for Medication Error Reporting and Prevention: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health professional, patient or consumer (Smith, 2004).

Drug errors can include miscalculation, over- dosing and underdosing (Preston, 2004). However, drugrelated incidents are rarely a result of isolated thoughtlessness. The underpinning causes are often complex and multifaceted, and nurses tend to view them as multiple-cause incidents (Preston, 2004).

Risk reduction A number of steps can be taken to reduce the risk of drug errors. When administering drugs it is important to follow the five Rs (Box 2) (Preston, 2004). Procedures should be in place and prescriptions clearly written in order to facilitate this. Verbal orders for drugs should not be accepted (NMC, 2004), nor should badly written prescriptions.

If prescriptions are illegible and instructions are vague the whole system is open to failure. Computer generated prescriptions can help to solve some of these problems but the system is not universal and has training implications for those using it.

All known allergies should be clearly documented and staff should be made aware of them and educated regarding appropriate actions.

Known areas of higher risk include:

- Anaesthetics;

- Intensive care;

- Paediatrics;

- Chemotherapy;

- Intravenous therapy.

The main groups of serious-risk drugs are:

- Anticoagulants;

- Anaesthetics;

- Chemotherapy;

- IV infusions;

- Methotrexate;

- Opiates;

- Potassium chloride.

Injections in any form come with their own set of potential risks (Smith, 2004).

Protocols should be carefully followed with high-risk drugs. These should include close monitoring of patients and staff, training of staff, and where appropriate, well-maintained infusion pumps.

The environment where drugs are prepared must be clean and with as few distractions as possible. Out-of-date medicines must be disposed of immediately. Where there is ambivalence about a prescription it must always be clarified and any confusion over calculations must be checked.

When patients move from one care setting to another all documentation must be complete and good communication is vital to facilitate continuity of care and ensure that supplies do not run out.

Nurses must be vigilant in checking calculations and in identifying any shortfall in their knowledge. If they are in any doubt it is essential to double-check with an appropriately qualified colleague. Nurses should also keep abreast of pharmacological developments and learn to calculate doses in different circumstances, regardless of external pressures.

Particular care must be taken with medications requiring a solution to be mixed or involving the use of decimal points. These can be confusing, especially if there is pressure to think quickly or if distractions or fatigue are factored into the scenario.

The human factor should also be considered. People make mistakes, and all health professionals are prone to moments of poor concentration and can miss something vital. Unfortunately, in health care the consequences of this can be fatal.

Patients also need to be well informed about any medications they are given and any likely sideeffects. Capable patients should be involved in their treatment, while relatives or carers can take on this role if the patient is not able to do so.

Reporting of drug errors It is generally believed that the number of reported drug errors is the tip of the iceberg (Hackel et al, 1996) and that far more go unreported. Fear, chiefly of management reprisal and the reaction of colleagues, often deters nurses from reporting incidents (Pape, 2001). However, it is essential to be vigilant about reporting in order to identify and rectify defective systems (DoH, 2000). The NMC (2004) advocates thorough investigation of all errors and incidents at local level.

Near misses as well as actual errors need to be reported so the incident can be assessed and analysed and any necessary changes made to enhance patient safety. This is done under bodies such as the NPSA and the National Institute for Health and Clinical Excellence.

The wider picture As treatments become more complex, tight control and minimisation of risk become increasingly important. Reducing drug errors, near misses and incidents does not only concern health professionals and patients - it is a matter of concern for governments globally, and sharing information may help countries to gain insight into patterns of drug error and enhance prevention (Smith, 2004). Health care providers also need robust systems to assist nurses in minimising the incidence of drug errors and in learning from those that do occur.

Facing up to a drug error Professionals self-esteem can be badly affected by drug errors (Arndt, 1994) and a real fear of negative consequences can delay the reporting of errors (Wakefield et al, 1996). However, a delay in reporting can have far-reaching consequences.

The first consideration must be for the patient and whether any serious harm has been done and what remedial actions are required. However, when health professionals realise they have made an error they may panic and try to cover up the incident. It is important for them to realise they have not

committed a crime - they have made a mistake. Even if it was born of complacency the reasons behind the error can usually be traced.

It is essential to be as accurate as possible when reporting an incident. Omitting information out of fear, real or perceived, does not help the long-term outcome. If systemic reasons led to the error and these are not identified the error will recur in the future. If any facts are omitted an incorrect picture of what happened may emerge (DoH, 2000).

It is essential for health professionals to obtain support if they have made a drug error. This may be from line managers, union representatives or occupational health workers. Talking through an error stops it from dwelling in the mind, while admitting to someone else that it happened helps to put the matter in perspective and can prevent the health professional concerned from blowing it out of proportion.

While it is important to complete statements and acknowledge the incident has happened, it must not be allowed to dominate the persons life. It may be appropriate for the person to take a few days of sick leave if the incident has caused enough stress affect her or his ability to practise safely. However, except in the most extreme situations, being at work and putting the incident in the past is the best way to cope with the aftermath of a drug error.

Moving on During the process of facing the consequences of a drug error, keeping a reflective journal can be a useful self-help tool (Wilkinson, 1999). Writing down details of the incident, the circumstances that contributed to it, personal reactions to the mistake and feelings arising from it, can be cathartic and will help put it into perspective. It can also be helpful as an aide memoire when reporting to any investigations. It can be helpful to reflect on a range of questions (Benjamin, 2003), such as:

- Could the error be attributed to a possible failure in the system?

- Could it have been prevented?

- Were all the appropriate actions taken?

- What changes need to be made?

- Is there a need for further education?

- Is the error likely to recur?

Dealing with the effects of a drug error quickly and efficiently limits damage and restores trust and confidence in the clinical area. It is important to keep the situation in perspective and not allow it to become blown out of proportion. If managed properly, it will be treated as an unfortunate incident and will not affect career opportunities.

Conclusion Good communication, clarity and vigilance are vital whenever drugs are being administered. Medicine administration is a skilled but potentially dangerous procedure and it is essential to be alert to possible pitfalls and to follow guidelines in order to minimise the risks.

When undertaking the administration of medicines nurses must be willing to take responsibility for their actions and rectify any shortfalls in their knowledge. However, for this to happen there needs to be a culture in which nurses can report errors or near misses without fear of reprisal. Incidents should be turned into situations from which lessons are learnt and progress is made.

Learning objectives Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:

- Understand what constitutes a drug error;

- Know how the risk of a drug error can be reduced;

- Explain the importance of reporting drug errors;

- Identify techniques for coming to terms with a drug error.

Guided reflection Use the following points to write a reflection for your PREP portfolio:

- Write about why this article is relevant to you and your practice;

- Identify the main points the article makes about drug errors;

- Outline anything new you have learnt about dealing with drug errors;

- Consider how you can use this information in your practice;

- Explain how you will follow up what you have learnt.

Nurses Role in Medication Administration

Last updated: Monday January 06, 2003

Much of nursing practice involves decisions about:

administration effects side effects of drugs

Implications for Nursing Practice

Dependent practice - by Prescription Interdependent practice - MD and RN consult Independent practice - nurse prepares and administers monitors for side effects patient teaching

Nurse is responsible for what, how, when, and how much is given Must question orders that seem incorrect or inappropriate

Nursing Implications

Responsible for understanding: expected effects untoward effects dosages and protocol to give actions to take in event of untoward reaction

Nursing Implications

DRUGS ARE LETHAL WEAPONS THERE IS A FINE LINE BETWEEN CORRECT DOSES AND LETHAL OR TOXIC EFFECTS

Definitions

PharmacokineticsWhat the body does to the drug PharmacodynamicsWhat the drug does to the body

Medication orders

Prescription from M.D. sometimes nurse practitioner (CRNP) or physicians assistant (PA) both may need to be co-signed by MD

Types of med orders

standing - until cancelled or d/c by agency policy or for particular symptoms prn - as needed (e.g. for pain) single order - once, at a certain time stat - immediately; once only

Essential parts of med order

client name date/time order written name of drug (generic or brand) dosage (metric or apothecary) o amount o frequency route signature

Routes of Administration

oral sublingual buccal rectal topical transdermal inhalation Parenteral subcutaneous intramuscular intradermal intravenous intraarterial

Medication Administration
5 "rights"

client medication dosage route time

within 1/2 hour

Safe medication administration

5 "rights" 3 checks o reach for container or unit dose packet o right before pouring or opening o as return container - BEFORE administering

Administering any meds

You prepare, you give. give within 30 minutes of time ordered identify client (check name band) explain to client if client questions drug or dose - STOP observe client take med o per agency policy o antacids, lozenges document after giving (or refused) monitor and evaluate client response

Administering oral meds

check if NPO, intact gag and swallow reflex position patient properly provide straw as needed crush or mix in food (e.g. applesauce) prn

Administering parenteral meds

Select appropriate size (guage) and length of needle o guage - 18 thru 27 o length - 1/2 to 2 inches Select appropriate size syringe o 1 - 3 ml Use aseptic technique Select appropriate site - IM, SQ, ID

Administering parenteral meds

Don disposable gloves Cleanse site

Inject quickly - 900 Aspirate (not heparin, intradermal) Inject medication Dispose in puncture-resistant container without recapping Record Evaluate

IM Site Selection

Dorsogluteal (buttock) Ventrogluteal (hip) Vastus lateralis (lateral thigh) Rectus femoris (anterior thigh) Deltoid (arm)

Needleless Systems/Protected Needles

recessed IV connectors blunt cannulas needles sheathed in plastic guard retractable needles

Measurement Systems

Apothecary o Basic unit weight - grain (gr) o Basic unit volume - minim (m) (@ drop) o 1 gr = 1 m = 1 drop o written with Roman numeral gr ii o Others: dram (z ) ounce pint, quart, gallon

Household

o o o o o

drop (gtt) 1 minim tsp (t) 4-5 ml (z ) @ 60 gtts 3 tsp = T (15 ml) 2 T = 1 oz (30 ml) 1 c = 8 oz

Metric
o o o o o

based on units of ten (decimal system) 3 basic units measurement length - meter (m or M; cm; mm) volume - liter (l or L; ml) weight - gram (g or Gm; mg)

Volume and Weight Equivalents

Basic principles of math

Roman numerals i, ii, iii, iv, v, x gr i, gr v 1/2 = ss Fractions Decimals based on tenths o R of . < 1.0 (0.78) o L of . > 1.0 (12.0) o Multiply by 10s, 100s, 1000s - move decimal point o Add or subtract keep decimals lined up Ratio and Proportion ratio - express relationship by division 1/3 or 1:3 proportion - 2 equal ratios 1/3 = 3/9 or 1:3::3:9 Product of means always = product of extremes use to solve for x

2 = 8 2:4::8:x 4 x 2 x = 32 x=

What you KNOW What you NEED DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give

Rx: Demerol 75 mg IM stat Have: Demerol 100mg/ml in vial DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give 100 mg :1ml :: 75 mg : x ml ( 100 = 75 ) 1 x 100 x = 75 x = ml

Rx: Cardizem 90 mg po qd Have: 60 mg / tab DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give 60 mg :1 tab :: 90 mg : x tabs ( 60 = 90 ) 1 x 60 x = 90 x = tabs

Rx: Lasix 40 mg IV push stat Have: 10 mg / ml DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give 10 mg :1ml :: 40 mg : x ml ( 10 = 40 ) 1 x 10 x = 40 x = ml

Rx: Amoxicillin 250 mg po q 6h Have: 500 mg/5cc DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give 500 mg : 5 ml :: 250 mg : x ml ( 500 = 250 ) 5 x 500 x = 1250 x = ml

Converting between systems of measurement

Rx: ASA gr v po qd Have: ASA 325 mg tabs How many tablets will you give? Use conversion factor - gr and mg Conversion factor? 1 gr = 65 mg (KNOW) What you KNOW What you NEED UNKNOWN/NEED ? 5 gr = x mg

What you KNOW What NEED TO KNOW 1 gr = 65 mg :: 5 gr = x mg (1) x = (65) (5) x = 325 mg (There are 325 mg in 5 gr) How many tablets will you give? 325 mg = 325 mg (5 gr) 1 tab x tabs 325 x = 325 x=

May need 2 steps

Rx: Lithium gr x po t.i.d. Have: Lithium 300 mg/capsule How many caps will you give? Conversion factor: 60 mg = 1 gr 60 mg : 1 gr :: x mg : 10 gr x = 600 mg (not caps) NOW 300 mg : 1 cap :: 600 mg : x caps 300 x = 600 x = 2 caps

Drugs measured in Units

Insulin 100U/ml Heparin 10-20,000U/ml Penicillin 400-800,000U/ml

Rx: 5,000U Heparin sq q 12h Have: 20,000 U/ml Can use Desired X Amount Have

5,000U X 1ml = 20,000U Give = 1 or .25 ml 4

Rx: 40U NPH Insulin sq q AM Have: 100U/ml in vial (U-100; U-50) Use U-100 syringe D X Amt 40U X 1ml = 0.4 ml H 100U OR ratio/proportion 100U:1ml :: 40U: x ml

100 x = 40 x = 0.4 ml

Drugs provided in powder form

Must be reconstituted for injection Rx: aqueous penicillin G 500,000 U IM Have: 5,000,000 U in dry powder in vial How many ml will you give? TRICK QUESTION!! You need to reconstitute - add diluent. Follow manufacturer directions.

Reconstitution instructions:

Add for U/ml 18 ml 250,000 8 ml 500,000 3 ml 1,000,000

How much diluent will you add?

(sterile water,NaCl) You want to give 500,000U per dose.

Add 8 ml diluent = 500,000 U/ml KNOW = UNKNOWN/NEED 500,000 U = 500,000 U 1 ml x ml 500,000 x = 500,000

x = ml

IV fluids

MD orders type solution amount " time of infusion

medications to be added to continuous infusion to intermittent infusion (IVPB) as bolus dose

Calculating milliliters per hour

Rx: 1000 ml NSS to run over 6 hours total volume = ml/hour total time in hours 1000 = 166.6 ml/hr 6 Round off to 167 ml/hr

Calculating Drops per Minute

Rx: Administer 1000 ml D5W every 8 hr. Drop factor is 15 gtt/min total volume x drop factor = gtt/min total time (in minutes) 1000 ml x 15 = 15000 8 x 60 480

= 31.25 gtt/min Round to 31 gtt/min

Common IV Drop Factors

Macrodrip 10gtt/ml 15 gtt/ml 20 gtt/ml Microdrip 60 gtt/ml

Rx: Kefzol 1 g IVPB q 6 h (Mix in 50 ml D5W. Infuse over 20 min.) Drop factor is 20 gtt/ml

Kefzol supplied as 500mg/ml.

How many ml will you add to 50 ml bag?

500 mg = 1g 1 ml x ml 500 mg = 1000 mg 1 ml x ml 500 x = 1000 x = ml

How many drops per minute will you run the Kefzol so it is absorbed in 20 minutes?

50 ml X 20 (drop factor) = 20 (time in minutes) 1000 = 20 Run at 50 gtts/min

Tips from Errickson & Todd

Write out units of measurement; must appear in same order

e.g. 60 mg = 90 mg (60mg:1tab::90mg:x tabs) 1 tab x tabs

line up decimals Re-check if odd answer e.g. 25 tablets !! Calculator only as good as your set-up

Names of drugs

Generic - assigned Official - as listed

USP, NF

Chemical - describes composition Trade or brand name Hydrochlorthiazide aspirin acetylsalicylic acid Bayer

Hydrodiuril

Classifications of Drugs
According to:

body system - cardiac clinical indication/effect - antibiotic composition - chemical symptom relieved/purpose - relieve pain

Kinds of Drug Actions

Therapeutic effect - desired Side effect - secondary or unintended

therapeutic should outweigh side effect

Kinds of Drug Actions

Adverse effects (FDA MEDWATCH) Iatrogenic disease

cumulative - drug level builds up drug tolerance- larger doses needed for same effect idiosyncratic - unexpected, peculiar

(e.g. elderly)

drug allergy - minor to serious immune reaction

anaphylactic reaction - sudden, life-threatening

Drug Interactions
Combined effect of 2 or more drugs alters effect of one or both:

antagonistic/inhibiting effect - lesser o antacids/milk with Tetracycline synergistic/potentiating effect - greater o e.g. alcohol and barbiturates

Demerol and Phenergan

Drug Standards
To predict effect based on consistency, uniform quality

Pure Food and Drug Act (1906) - must be listed in o US Pharmacopeia (USP) o National Formulary (NF)

Drug Laws

Federal Food, Drug, Cosmetic Act (1938) o extensive testing of new drugs Comprehensive Drug Abuse Prevention

and Control Act (1970) (Controlled Substances Act)

o

must have prescription for controlled substances:

narcotics, amphetamines, barbiturates, tranquilizer

Harrison Narcotic Act o controlled substances must be kept in double-lock system

State Nurse Practice Acts

Prescriptive rights for NPs Administering drugs IV push Question and/or refuse to give incorrect or contraindicated order

Decimal Point Dangers

Rx: dexamethasone .10 mg IV q 12h x 72 h Transcribed as 10 mg Avoid error by: writing as dexamethasone 0.1 mg dont use "0" after decimal point if 1.0 mg - write "1 mg" instead

Variables Influencing Drug Actions

Weight usually based on 70 KG person sometimes BSA- especially children sometimes on time mcg/kg/min Gender generally based on amount of body fat & H2O fewer studies done on women - hormonal effects

Variables Influencing Drug Actions

Genetic factors variations in enzymes to process meds variations in amounts needed for therapeutic effects Cultural factors health beliefs can affect use of medications

Variables Influencing Drug Actions

Psychologic factors expected response to medication Clinical trials/research compare effects of active drug vs placebos only ethical place for placebos Signed informed consent

Variables Influencing Drug Actions

Pathology illness states or disease affects drug absorption especially true in organs that metabolize drugs o renal failure o hepatic failure Cachexia

altered albumin levels

Variables Influencing Drug Actions

Environment Surroundings may enhance or diminish expected effects of medications

Z-track Injection Method

Used for irritating medications Prevents "tracking" through layers of tissue Make sure needle is free of medication

(change needle or wipe off) Questions ?

of Medication Administration with NursingImplications 1. Right Medication. The medication given was the medication ordered. Nursing Responsibility: Check three times for safe administration. Read the medication administration record (MAR) and compare thelabel of the medication against it. Check the expiration date of the medication. If the dosage does not match the MAR, determine if youneed to do a math calculation. While preparing the medication, look at the medication label and check against the MAR. Recheck the label on the container before returning to its storage place. 2 . Right Amount / Dose. The dose ordered is appropriate for the client. Nursing Responsibility: Give special attention if the calculation indicates multiple pills/tablets or a large quantity of a liquid medication.This can be a cue that the math calculation may be incorrect. Double check calculations that appear questionable. Know the usual dosagerange of the medication. Question a dose outside of the usual dosage range. 3. Right Patient/Client. Medication is given to the intended client. nurse to use at least two client identifiers whenever room number. Acce identification number, photograph, or other person-specific identifier. Check the clients identification band with each administration of medication. s with the same or similar last names are on the nursing unit. 4 . Right Route. Give the medication by the ordered route. Nursing Responsibility: Make certain that the route is safe and appropriate for the client. Clients may require physical assistance inassuming positions for intramuscular injections. 5 . Right Time and Manner. Give the medication at the right frequency and at the time ordered according to agency policy. Nursing Responsibility: Medication given within 30 minutes before or after the scheduled time are considered to meet the right timestandard. The nurse should also check institutional policy concerning administration of medications. Hospitals often have standardized interpretations for abbreviations. The nurse must memorize and utilize standard abbreviations in interpreting, transcribing, and