Medication Errors....

[momandstudent]

I am the occ. health/education/infection control nurse at a SNF and I am trying to come up with some material to help alleviate medication errors among our nurses. Right now, when an error is found, a form is filled out and the nurse and DON discuss what happened and what steps will be taken to prevent further mistakes. Many, many times, the nurses say, "Will pay closer attention or will take more time during the pass." Our DON is new and would like me to come up with some sort of "homework" for the nurse(s). She did give me a packet to go through this weekend which is about 60 pages of combined reading and essay questions. I have not thoroughly read it (it is the weekend ) but I was wondering if anyone else had any good ideas. I am going to post this in some other areas on the board but thought I would start here as it gets more traffic!!!! Thanks for any input.

[AngelRN27]

It seems from your post that the only intervention being implemented is a nurse "remediation" but that isn't always the core of the problem. Is any investigation done as far as the individual error? Are several medications labeled similarly? Is there another medication check that can be done? Are similarly named meds marked or red-flagged?

I guess I would have to know the nature of the med error to offer helpful suggestions...

[lauriepat, ASN, RN]

Like angel said..is it a certain nature of med errors?

Not sure if you guys use computer documentation or handwritten MAR's, at my facility we have "mar checks" at the end of every shift, the med techs (we have med techs in va..sigh) trade books and look for holes or missed spaces that may have been missed/not signed.

It may help too if you get your nurses to make like a guide, or cheat sheet to each cart/med

pass..like who gets meds crushed, who wants meds exactly on time, or an hour before or an hour after sched time..etc. This may help someone who is covering the cart and cut down on errors/frustration.

[CapeCodMermaid, RN]

There are dvd's about safe medication practices....joint commission has good information.....or call your pharmacy consultant for some recommendations.

[jamd11]

If its a matter of being interrupted.... My institution has a policy that visitors and other staff are not allowed to interrupt nurses who are doing med passes unless its an emergency. We have a sign we put up on the med cart that basically says do not disturb and we have a pad of paper on our med carts that other staff and write on for us to see after our med pass.... We also use eMAR and I find this has been extremely beneficial in allowing me to stay organized, manage my time and check check check before I walk off to administer!

[Sun0408, ASN, RN]

You really can't just look at the med error it's self, it must be looked at as a whole. What is the time frame for med passes, how many pts, how many different locations the pts are in.. Was the order written clearly,transcribed correctly, was it actually verified?? Is this paper MAR's or electronic..

I don't know of one nurse that intentionally makes a error..

[ktwlpn, LPN]

>>>>>>>>Many, many times, the nurses say, "Will pay closer attention or will take more time during the pass." Our DON is new and would like me to come up with some sort of "homework" for the nurse(s>>>>>>>>

Like writing a thousand times " I will pay closer attention and will take more time during med pass?" I'm not too keen on the homework idea,I find it demeaning. A 60 page packet of homework with reading and essay questions? I can't see where that would be of any benefit. We have progressive discipline ,first med error results in counseling. That's when you discuss what you did wrong and how you could have prevented it. Second med error (within a year)results in watching a DVD about proper admin of meds and the third will result in termination.

[wyogypsy, RN]

In my years of nursing, many of them in LTC, I have found that most med errors are due to nurses not using their MARs. They pop the meds out of the blister packs, pop them out of the pre-filled packages for each med time, etc. The reason they give for not using their MARs is that they don't have time, or that they give those meds so often they know them by heart. Amazing how many med errors can be found then by the relief nurse that does use the MARs. When I follow a nurse that uses her MARs, I rarely find an error. I believe you can pass meds on any med cart in a LTC facility and by the end of the med pass you can tell which nurses do, and which nurses don't, use their MARs. Kudos to those that still know comparing your meds to the MAR is an important safety measure that doesn't go out of style.

[DalekRN]

A med error I made while working in ltc would have been prevented if the residents wore identification.

[chrisrn24]

A med error I made while working in ltc would have been prevented if the residents wore identification.

But it's their home though. I don't agree when I hear some facilities have them wear wristbands.

[CapeCodMermaid, RN]

Let's face it, some nurses are too lazy (flame away) to pass meds the way they were taught....oh wait....maybe in the 10 months they spent in LPN school they weren't taught enough.

[Sassy5d]

I think it boils down to the MAR. If you pull a med, check it even once against mar and then know your pt, you can't make a mistake.

The problem lies in polypharmacy. You have 20+ pts to pass meds to in 2 hours. Meds are constantly being dc'd then added. Meds don't get pulled from cart, or pharmacy accidentally delivers wrong med.

nurses are passing meds they don't even know what they are for. Having pts swallow spiriva caps.

I think essays and the like are not a good idea. Nobody likes reading that much information.

I think holding nursing accountable. If you take a new order, you should be pulling the med out of the drawer, or separate the new orders so someone can audit the carts and make sure meds are up to date. But it still falls on the nurse to use the MAR.