Medication Errors - page 3

I am doing a research paper on medication errors. Curious as to what nurses think about this subject. What do you think are the most common medication errors and what are the most common reasons for... Read More

  1. by   NRSKarenRN
    Check out the website of the Institute for Safe
    Medication Practices @ http://www.ismp.org/

    They have many articles re preventing drug errors for all involved in the process. Interesting tibits re sound alike drugs too.
  2. by   boggle
    Next to being rushed, I find not pouring meds at the bedside leads to the most errors. It is too easy to pour meds at the med cart, sign the MAR, then walk down the hall to the patient room to give the dose. Way too many mistakes can happen on the way down that hall!
    I swear by checking med against MAR and pouring at the bedside. There's no interruption, the patient name and name/dose of each med is right there, and you can document administration or refusal right away.
  3. by   shannonRN
    boggle i hear you. where i used to work one of the externs (a nursing student who works in the hospital) walked out of the med room and into the wrong patients room and gave the meds. hospital policy, at the time, was for a RN to double check the extern's meds before they could give them to a patient. unfortunately the patient died, however, we do not know if it was a direct result of the med error. the hospital changed the policy and now only RNs are allowed to pass medications.

    i find that another reason for med erros is not reading the mar to the end. my hospital lists the meds as follows; name of drug, dosage, #of pills, and how often. for example, glucophage 500mg #2 Q am. alot of the nurses stop after the 500. and only give one pill instead of two.

    hope this helps!
  4. by   route six six
    wow
  5. by   a/ox3RN
    Originally posted by KellyandtheBoys
    I think the most common reason for medication errors is being "too rushed". When we don't have enough time to take those precious extra seconds to be careful med errors are just waiting to happen.

    I would think a most common error would be wrong dosing. For instance if a ptl. is to receive 25 mg. of lopressor. The nurse has a 50 mg. pill. In haste she gives the entire pill rather then breaking it in half. I know this has "ALMOST" happened to me several times. I thank goodness I have done the double and triple checks that prevented these errors. But, when rushed I can see errors like this happening.
    when i was a new grad, i had a pt whose apical pulse was 120-130, so i gave her cardiac meds, one was lopressor. but there was a question about her other med dose, so i immediately found the doc and started asking him about it. i don't recall how, but suddenly he said, lopressor only comes in 50's, you didn't give her the whole pill, did you?
    yes i did.
    i think my heart stopped. i went back and checked, and sure enough, gave her the whole pill, 50, instead of the 25.
    he ordered a stat ekg and turned out she was in a fib before i gave it, and that he would've told me to give the extra dose to treat it. she improved during the day, but i was completely wrecked for the rest of the day, because i kept thinking he was just being nice to me.
    but you know, now i wonder, if they can make a different pill with different colors for different doses for coumadin, why not for lopressor?

    i check all that much more carefully now.
  6. by   Fgr8Out
    Last edit by Fgr8Out on Jul 20, '02
  7. by   Fgr8Out
    "Moonshadeau: I had intended to write a note on what occured, but was unable because of the chart review. "

    Now, I'm not saying this is fair but... the rule of Nursing "Not charted, not done" seems to apply here. You did right by noting the B/P though, and that should have been evidence enough to cause anyone reviewing a chart to figure out the reason why the med was given early. I tend to agree that the reviewers were looking for something to be amiss....

    5 Rights:
    Right Patient
    Right Drug
    Right Time
    Right Route
    Right Dose

    I also like the suggestion by ClarisseS about checking the packaging on the medication you're in the process of giving 3 times: as you're originally taking it out of the med drawer, as you're pulling up (or opening) the med, and as you toss the packaging away. Without thinking about it, I realized as I read that suggestion that it is exactly what I do.

    Additionally, I often don't actually open a PO medication until I'm at the patient's bedside. I've had to throw away meds too many times due to a patient not wanting the med or something happening along the way that causes me to rethink giving this or that drug.

    Lastly.... Check Your Armbands!!!! I can't emphasize this enough. I am daily confronted by a patient who, while I'm checking their name band (the 1st time I give them a med... to the 30th time I give them a med), "You're the first person to ever check my name." NEVER assume that because a patient answers to the name you call them by... or that because they don't question the medication you're giving, that they are the intended recipient. EVER. When I explain my rationale to a patient who I have been giving the same medication to for 3 days... "Mrs. Renal Failure, I sometimes get busy and pulled away from the task at hand, so I always check who I'm giving a medication to because I want to be certain I'm doing my job as safely as I can" ... I NEVER meet with resistance and my patients are very much reassured to know how careful I am with their medication administration. It certainly helps instill confidence in them... and our patient's need all the confidence we can instill.

    Terrific Thread!!!!

    Peace
  8. by   adrienurse
    I find that if I ever make a med error it is due to distraction. The phone is ringing, or somebody is having a problem outide the med room or somebody is trying to get my attention. I work on a very noisy psychogeriatrics unit. I refuse to answer call lights when I am pouring meds. I have been known to shut myself in the medroom until I am finished.
  9. by   gwenith
    I have a legitimate complaint against pharmaceutical companies and how they unconsciously and unthinkingly make our job so much harder. How many nurses have had to squint at labels are printed in pale colours and fine writing? How annoying is it to try to see the expiry date when it has been stamped into the plastic of the ampoule in such a fashion that it is only visible if it is held at JUST the right angle in the light? Have you ever struck a drug where the information on how to administer it is so obscure that it takes 15 minutes to track down a reference! Let's start an annual award system i.e.

    1) THE EYE STRAIN AWARD - for the worst labelling of ampoules
    2) THE TREASURE HUNT AWARD - for the most obscure reference on how to administer a drug.
    3) The BOOBY TRAP AWARD - for the company that consistently produces ampoules that either disintegrate in your hands or fall apart in some way.
    4) ALADDIN'S CAVE AWARD - for ampoules/vials that either need a chisel, hammer and a brick to open or have some secret system that no-one can figure out.

    I am sure that more awards can be offered but lets start and if we cannot make the pharmaceutical companies think about how to make the nurses job a little easier then at least they can stop making our life so difficult.
  10. by   Cascadians
    Many medication errors are caused by rushing, haste, sloppiness, distractions, interruptions, and TOO MANY PEOPLE HANDLING THE PAPERWORK.

    The responsibility of medications should rest with the DOCTOR. S/he should enter the order by computer. It must be spelled correctly, etc. That information should automatically be immediately sent to the pharmacy (not squiggly blurry faxes!) The pharmacy should promptly fill and deliver order to correct pt's drawer with BIG CLEAR labels! The pt's RN should be immediately notified by a BIG CLEAR written copy of the order auto-printed after pharmacy receives and checks Dr's order. The MARS must be auto-updated every shift in big clear print, and assiduously notated and signed, etc.

    Cannot tell how many horrifying experiences of seeing illegible Dr writing, illogical med orders, MARS filled out by untrained clueless unit clerks or facility secretaries distracted by innumerable pressing interruptions, "lost" paperwork rammed up behind desks / cubicles, error-filled lab orders, smeared-labeled tubes, etc etc etc.

    There is too much haste and waste in the flurry of paperwork duplication. It's like the "telephone" game where the message gets more distorted with each telling.

    /end rant
  11. by   lever5
    Is there anyone here that says " I never made a med error".
  12. by   Fgr8Out
    Originally posted by Cascadians
    end rant
    :: giggles ::
  13. by   boggle
    No way!!! I've told my error stories often to illustrate how easy it is to make the same mistakes, and ways to avoid making the same mistakes. I'm so lucky no harm was done by my errors.

    I also tell how HORRIBLE it felt to realize the mistake was made and to go through the process of notifying everyone, writing it up, getting counseled by the supervisor........

    The worst was watching and worrying about the patient (no harm done thankfully!), and realizing how easily it could have been a disasterous outcome.

    Disaster or not, it could have been the end of my job and career.

    In my many years of nursing, so many improvements in delivery of care and meds have come from errors and near misses.
    Last edit by boggle on Jul 20, '02

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