Looking for website where I could find information for a presentation on Med errors?

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Does anyone know of an interesting website where I could draw some information for a presentation on Med errors? I would like to include things that my fellow student nurses (aka future RNs) really need to know. Maybe things that are considered med errors that we would have never thought of?

Thanks so much! =)

~J

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Specializes in Operating Room.

Expiration dates not being checked could be one.

I know as a Medical Assistant, I always documented the expiration date, bottle code and injection site (or other method). Many did not do this, but I did it for a C.M.A....Cover My ARSE. :rolleyes:

Good luck! :)

Does anyone know of an interesting website where I could draw some information for a presentation on Med errors? I would like to include things that my fellow student nurses (aka future RNs) really need to know. Maybe things that are considered med errors that we would have never thought of?

Thanks so much! =)

~J

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Specializes in med/surg, telemetry, IV therapy, mgmt.
Does anyone know of an interesting website where I could draw some information for a presentation on Med errors? I would like to include things that my fellow student nurses (aka future RNs) really need to know. Maybe things that are considered med errors that we would have never thought of?

Thanks so much! =)

~J

There is a committee that I believe is under the supervision of Medicare that is doing a study of medication errors over the next few years. I can never remember the name of the agency that is doing this, but someone had mentioned it in a response to one of my old posts. I just did a bit of a search and still could not find it. I can tell you that this subject is a hot topic with Medicare right now because they have been compiling some awesome statistics about how medication errors are increasing days of stay in the hospital. Also, untoward and allergic reactions to medications have been found statistically to be upwards of 30 to 40% of the reason for hospital admissions (this is Medicare information) and a sizeable number of deaths.

Try doing a search for medication errors on Medicare's web site. You might also check the website of your state's board of nursing or call them for information. A lot of states are jumping on the wagon and participating in this medication error initiative. You've picked a very hot topic and will probably be seeing Medicare promoting legislation in an effort to try to control the number of medication errors committed. This is actually good for our team.

That aside, got back to the 5 R's of medication administration. Anytime one of those 5 R's is not followed a tragic med error often follows. Also, do a search of these forums for "medication errors". You will find a host of stories on medication errors people have posted about. Some will curl your hair and make you wonder how some nurses could be so stupid! One good story could make a very good opening antecdote for your presentation. This is just an idea, but you might try a web search for information on the Pixis system. The company who makes the Pixis, which is one way hospitals put their controlled substances under supervision, might have some interesting info. Good luck. Have fun. If I come across the name of that national committee I'll post it here for you.

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Wonderful suggestions, thank you so much. I had no idea about the study of ME within the medicare system. I will check that out. It will be an interesting topic....and you are right....I will search this forum too. I have read a few scary ME stories right here. =)

Thanks!

~J

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Specializes in Gerontological, cardiac, med-surg, peds.
Does anyone know of an interesting website where I could draw some information for a presentation on Med errors? I would like to include things that my fellow student nurses (aka future RNs) really need to know. Maybe things that are considered med errors that we would have never thought of?

Thanks so much! =)

~J

The absolutely best site is the Institute for Safe Medication Practices (ISMP):

http://www.ismp.org/NursingArticles/index.htm

http://www.ismp.org/PDF/Patient_Broc.pdf

http://www.ismp.org/MSAarticles/calendar/calendar.html

ISMP offers a free monthly newsletter (Medication Safety Alert!) which is available by e-subscription.

Other GREAT resources:

http://dynamicnursingeducation.com/class.php?class_id=38&pid=15&PHPSESSID=92d3267d550c97f9fd90472cf349869b

http://www.nso.com/resources/artcls_abbrevs.php

http://www.nso.com/newsletters/features/common.php

http://www.jcaho.org/accredited+organizations/laboratory+services/npsg/06_dnu_list.pdf

A medication error involves violation of one of the cardinal 7 rights of medication administration:

1. Right patient (two identifiers)

2. Right medication

3. Right time

4. Right dose

5. Right route

6. Right documentation

7. Right reason

Examples of "untraditional" scenarios which are considered med errors:

Crushing tablets that should not be crushed.

Use of discontinued or out-of-date medications.

Pushing an IV medication too rapidly or undiluted (when it should be diluted for patient safety).

Giving a patient (with a dig level of 2.5) the prescribed digoxin.

Administering the prescribed furosemide to a patient with a BP of 70/40.

Not documenting the site of an intramuscular injection (this could really come back to bite you in the event of a lawsuit)...

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Just wanted to post that I got my current issue of Nursing 2005 and in the medication error section it mentions that the medication errors it is reporting are from USP-ISMP Medical Errors Reporting Program and gives the web site http://www.ismp.org which VickyRN also listed in the last post to this tread. ISMP stands for the Institute of Safe Medication Practices. I don't know if the site lists some of these med errors, but there was a doozy in the journal of a patient who died after accidentally receiving an IV injection of the liquid inside a gelatin capsule of Nimotop that was meant to have been given into his NG tube. If you don't get the journal or don't have access to it I think I can manage to type it pretty rapidly for you if you want to read it.

There is also a very classic med error involving oral Digoxin given IM to a child by a nursing supervisor who was helping the staff RN out. The baby died. The supervisor gave the amount that should have been for an oral dose after being unsuccessful at reaching the doctor to verify the dosage. The doctor didn't write the route on his order and the supervisor was apparently not aware of the different between oral and IM doses assumed it was to be given IM.

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I replied to Vicki the yesterday but it's not here. Hmmm. I wanted to say thank you for those links! I have searched through this website and found many other awesome links you have posted! =) I bookmarked them and as soon as I finish studying for my midterm on Monday I will be utilizing those for my assignment.

Daytonite...that article sounds very interesting. I knew that it could be ugly for the wrong route, but wow...how awful to hear about personal stories like that. It truly gives me shivers to think I will have my patient's lives in my hands. I am hoping that this message will become very clear with what I can gather. Thank you so much...I will see if I can access that Journal through my school...we have full text to quite a few articles. It sounds like a good one. :)

~J

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Specializes in med/surg, telemetry, IV therapy, mgmt.

The medication errors is a regular monthly feature in Nursing 2005. I stopped my subscriptions to RN and AJN, but I wouldn't be surprised if they also had a monthly medication error section as well.

I love the word "poofed". Ha! Ha! There are times when I am so worked up while I'm writing a post that instead of clicking on "Submit Reply" I'll go to the top of the page and click on the link to get me back to a list of the posts in the forum I was looking at. Duh! Then, I can't find the post I made. I've discovered that you can get your message back if you're aware that it didn't post if you click on your "Back" button. Mine will hold about the last 8 or 9 "Preview Posts" I've made. I sometimes will cut and paste a post to a word document so I can go off-line and type and correct using my spell checker, especially my longer posts. I have a dial-up ISP so I don't like to stay on line too long during the day, otherwise I get calls from angry relatives (when the line is free) that they can't get a hold of me on the phone. Ha! Ha! For this reason I'll do a lot of posting during the night. I don't sleep well either.

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Specializes in Gerontological, cardiac, med-surg, peds.

Another great "find" - Med League's Topics on Medical Errors

http://www.medleague.com/Articles/medical_errors/index.html

This one contains excerpts from videos and articles.

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Awesome! Thanks Vicki, you are a great resource.

~J

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I just did a presentation on Med errors and I used a story I heard about an 18 mo old who died because of a med error....the website is www.josieking.org. I read the mothers story to the class....there wsn't a dry eye in the place

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My ME discussion was due Friday, and I wish I had this sooner...what a sad story, but it made an impact on me just reading it. When my daughter was two, I caught the nurse who was about to make a med error on her. They were giving my 18 lb. child a quintuple dosage of concentrated tylenol (not anything like narcotics, but still). I told the nurse that it didn't look right...she was measuring it as if it were childrens tylenol, not the concentrated drops. I told her she could not administer that to her without checking with the charge nurse or SOMEONE...mind you I was only 20 at the time. So I followed her to the nurses station and she checked with the charge nurse. It was very wrong. I remember her facing her back to me and removing most of the tylenol from the syringe then went in to give it to her. Never even an apology.

This story was so sad about this little girl. Thank you for sharing...

~J

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