Need assistance with medication errors

[1pinkrose]

I need some information regarding medication errors from a charge nurse or supervisor, and also from a staff nurse that has been working for at least 6 months.

From the charge nurse / supervisor I need to know:

1. What is the frequency of med errors in your area of responsibility?

2. What are your responsibilities when an error occurs?

3. Have you had to develop educational plans or give letters of counceling because of med errors?

4. What hospital committee makes decisions regarding med errors?

5. What advice do you have for a new graduate nurse?

6. How are med errors traced by nursing to find causes and improve client care?

7. How often are med errors made as a result of physician or pharmacy error?

8. How do you know if all med errors are being reported?

9. Have you ever had to discharge someone due to medication errors?

From the staff nurse I need to know:

1. What did you learn about med errors in your nursing program?

2. What do you believe is the cause and frequency of med errors?

3. How often do you believe nurses fail to report med errors that they make?

4. What do you feel are the reasons for med errors not being reported?

5. What is the procedure when a med error occurs?

6. What do you feel would be the most helpful information you could give to a new graduate to prevent or lower the incidence of med errors?

7. How are med errors used to continuously improve the care of the client?

8. What has been the most fatal med error that you know of?

9. In your opinion, what do you define as being a med error?

Thank you in advance! I appreciate you taking the time to share your experiences with me!

[jh479352]

In the day health I worked in it was alot of politics, if the nurses happened to be friends then they would not fill out an incident report. As far as the supervisor she did not come up with any solutions for errors, except one solution. I had to try and figure it out myself. There were alot of med errors because our system was very dangerous and it wasn't working. I'd like to hear more about answers to your questions because I was the one fired.

[Daytonite, BSN, RN]

from the charge nurse/supervisor here's what i know:

1. what is the frequency of med errors in your area of responsibility?

average is 5 per month

2. what are your responsibilities when an error occurs?

make sure proper procedure has been followed: doctor notified, incident report completed

3. have you had to develop educational plans or give letters of counseling because of med errors?

yes. if more than one medication error is committed within a 6 month period a mandatory medication review self-learning module must be completed by the nurse at the end of which a post exam must be completed and passed at 90% correct. this would be noted on the employees yearly evaluation as a specific item. official disciplinary action would only be started if the nurse committed the same type of medication error more than twice within a 6 month period. disciplinary action would also be started immediately if a patient were injured in some way because of the medication error.

4. what hospital committee makes decisions regarding med errors?

quality improvement

5. what advice do you have for a new graduate nurse?

follow the 5 r's of medication administration that you were taught in school. check each medication label three times before giving it. confirm each patient's identity by checking the patient's id band or having them say their name to you.

6. how are med errors traced by nursing to find causes and improve client care?

it is my responsibility as the manager to investigate the circumstances surrounding each medication error since the incident reports are usually brief and the charts usually do not contain more than physician notification. i usually end up having to interview the nurse(s) involved to find out exactly how the error occurred and/or how it was discovered. my findings are written on the back of the incident report or on a separate memo if more writing space is required and become part of that particular incident report.

7. how often are med errors made as a result of physician or pharmacy error?

rarely

8. how do you know if all med errors are being reported?

good question. we look at the qi tracking each month. things usually run in pretty regular trends. when you suddenly have a dry period of several months of no medication errors, you have to wonder why and if it is because they are not being reported. in all honesty, however, you really have no way of knowing.

9. have you ever had to discharge someone due to medication errors?

yes. (1) a licensed nurse was witnessed directing an unlicensed caregiver to give a patient an injection of insulin, (2) an rn was observed by another rn just as she completed injecting oral morphine elixir into a patient's iv

[TallGirlAni]

Where I work, we have the BCMA (bar code medication administration). I can't think of any other better system. We have med carts with lap tops on them and the patient wears a barcode wristband with his name and ss#, etc. If you do not take shortcuts and follow proper protocols, I can not think of a way one could have a med error (unless one does not follow the right patient, dose, route, etc.). The nurse rolls the med cart to the patient's room, types in her password, scans the patient, and all of the pt's info pops up on the computer screen. Then, the nurse scans out the medication. If it is the wrong med, or dose, the computer will prompt the nurse. Also, it lets you know the time the medication is to be administered, dose, etc. All of the meds are in the pt's drawers on the carts (except for narcs), and if a med is missing, we can send for a missing dose on the computer and it comes from pharmacy via tube system. Also, less room for error in transcription from doctor to pharmacy to nurse, because all charting is computerized and poor handwriting is never an issue. Also, you can prompt the computer to give you a list of missed meds, so if you forgot oe, you can give it. If one properly follows the procedures of this system, it is a more efficient of dispensing meds and has a much less risk of med errors. Although med errors still occur, the system definitely helps to cut them down.

[1pinkrose]

Thanks to all of you for the great information. It will be very useful for the paper that I need to do. If there are others out there that wish to share, please do! The more information I have, the better.