Need assistance with medication errors

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