preventing and reporting drug administration errors

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Preventing and reporting drug

administration errors16 August, 2005

Any nurse who has made a drug error knows how stressful this situation can be. Registered

nurses are accountable for their actions and omissions when administering any medicines

and must take responsibility for any errors they make.

ABSTRACT

VOL: 101, ISSUE: 33, PAGE NO: 32

Chloe Copping, RGN, is practice nurse, Buckden Surgery, Cambridgeshire

Any nurse who has made a drug error knows how stressful this situation can be. Registered nurses are

accountable for their actions and omissions when administering any medicines and must take

responsibility for any errors they make.

However, the increasing demands placed on nurses can render them more prone to drug errors.

Overwork can affect concentration and competence and this can be exacerbated by erratic working

hours and stress, while complacency can also lead to mistakes (Parish, 2003). While nurse fatigue is a

commonly cited cause of drug errors, others include illegible physicians’ handwriting and distractions

(Mayo and Duncan, 2004).

In its guidelines for the administration of medicines, the NMC (2004) outlines the information a

prescription must contain for safe and correct drug administration and gives clear principles for

prescribing medicines (Box 1). If the prescription is clear and accurate, errors are less likely to occur.

Health care providers have a responsibility to identify and minimise high-risk areas or conditions,

which include those where paediatric medicines are calculated and administered, and clinical areas

that use large quantities of controlled drugs (Smith, 2004).

Defining a drug error

There is a range of opinion about what constitutes a drug error (O’Shea, 1999) and nurses,

pharmacists and doctors may not actually agree on what the precise definition is.



- Intensive care;

- Paediatrics;

- Chemotherapy;

- Intravenous therapy.

The main groups of serious-risk drugs are:

- Anticoagulants;

- Anaesthetics;

- Chemotherapy;

- IV infusions;

- Methotrexate;

- Opiates;



- Potassium chloride.

Injections in any form come with their own set of potential risks (Smith, 2004).

Protocols should be carefully followed with high-risk drugs. These should include close monitoring of

patients and staff, training of staff, and where appropriate, well-maintained infusion pumps.

The environment where drugs are prepared must be clean and with as few distractions as possible.

Out-of-date medicines must be disposed of immediately. Where there is ambivalence about a

prescription it must always be clarified and any confusion over calculations must be checked.

When patients move from one care setting to another all documentation must be complete and good

communication is vital to facilitate continuity of care and ensure that supplies do not run out.

Nurses must be vigilant in checking calculations and in identifying any shortfall in their knowledge. If

they are in any doubt it is essential to double-check with an appropriately qualified colleague. Nurses

should also keep abreast of pharmacological developments and learn to calculate doses in different

circumstances, regardless of external pressures.

Particular care must be taken with medications requiring a solution to be mixed or involving the use of

decimal points. These can be confusing, especially if there is pressure to think quickly or if distractionsor fatigue are factored into the scenario.

The human factor should also be considered. People make mistakes, and all health professionals are

prone to moments of poor concentration and can miss something vital. Unfortunately, in health care

the consequences of this can be fatal.



Patients also need to be well informed about any medications they are given and any likely side-

effects. Capable patients should be involved in their treatment, while relatives or carers can take on

this role if the patient is not able to do so.

Reporting of drug errors

It is generally believed that the number of reported drug errors is the ‘tip of the iceberg’ (Hackel et al,

1996) and that far more go unreported. Fear, chiefly of management reprisal and the reaction of

colleagues, often deters nurses from reporting incidents (Pape, 2001). However, it is essential to be

vigilant about reporting in order to identify and rectify defective systems (DoH, 2000). The NMC

(2004) advocates thorough investigation of all errors and incidents at local level.

Near misses as well as actual errors need to be reported so the incident can be assessed and analysed

and any necessary changes made to enhance patient safety. This is done under bodies such as the

NPSA and the National Institute for Health and Clinical Excellence.

The wider picture

As treatments become more complex, tight control and minimisation of risk become increasingly

important. Reducing drug errors, near misses and incidents does not only concern health professionals

and patients - it is a matter of concern for governments globally, and sharing information may help

countries to gain insight into patterns of drug error and enhance prevention (Smith, 2004). Health

care providers also need robust systems to assist nurses in minimising the incidence of drug errors

and in learning from those that do occur.

Facing up to a drug error

Professionals’ self -esteem can be badly affected by drug errors (Arndt, 1994) and a real fear of

negative consequences can delay the reporting of errors (Wakefield et al, 1996). However, a delay in

reporting can have far-reaching consequences.

The first consideration must be for the patient and whether any serious harm has been done and what

remedial actions are required. However, when health professionals realise they have made an error

they may panic and try to cover up the incident. It is important for them to realise they have not



committed a crime - they have made a mistake. Even if it was born of complacency the reasons

behind the error can usually be traced.

It is essential to be as accurate as possible when reporting an incident. Omitting information out of

fear, real or perceived, does not help the long-term outcome. If systemic reasons led to the error and

these are not identified the error will recur in the future. If any facts are omitted an incorrect picture

of what happened may emerge (DoH, 2000).

It is essential for health professionals to obtain support if they have made a drug error. This may be

from line managers, union representatives or occupational health workers. Talking through an error

stops it from dwelling in the mind, while admitting to someone else that it happened helps to put the

matter in perspective and can prevent the health professional concerned from blowing it out of proportion.

While it is important to complete statements and acknowledge the incident has happened, it must not

be allowed to dominate the person’s life. It may be appropriate for the person to take a few days of

sick leave if the incident has caused enough stress affect her or his ability to practise safely. However,

except in the most extreme situations, being at work and putting the incident in the past is the best

way to cope with the aftermath of a drug error.

Moving on

During the process of facing the consequences of a drug error, keeping a reflective journal can be a

useful self-help tool (Wilkinson, 1999). Writing down details of the incident, the circumstances that

contributed to it, personal reactions to the mistake and feelings arising from it, can be cathartic and

will help put it into perspective. It can also be helpful as an aide memoire when reporting to any

investigations. It can be helpful to reflect on a range of questions (Benjamin, 2003), such as:

- Could the error be attributed to a possible failure in the system?

- Could it have been prevented?



- Were all the appropriate actions taken?

- What changes need to be made?

- Is there a need for further education?

- Is the error likely to recur?

Dealing with the effects of a drug error quickly and efficiently limits damage and restores trust and

confidence in the clinical area. It is important to keep the situation in perspective and not allow it to

become blown out of proportion. If managed properly, it will be treated as an unfortunate incident and

will not affect career opportunities.

Conclusion Good communication, clarity and vigilance are vital whenever drugs are being administered. Medicine

administration is a skilled but potentially dangerous procedure and it is essential to be alert to possible

pitfalls and to follow guidelines in order to minimise the risks.

When undertaking the administration of medicines nurses must be willing to take responsibility for

their actions and rectify any shortfalls in their knowledge. However, for this to happen there needs to

be a culture in which nurses can report errors or near misses without fear of reprisal. Incidents should

be turned into situations from which lessons are learnt and progress is made.

Learning objectives

Each week Nursing Times publishes a guided learning article with reflection points to help you with

your CPD. After reading the article you should be able to:



- Understand what constitutes a drug error;

- Know how the risk of a drug error can be reduced;

- Explain the importance of reporting drug errors;

- Identify techniques for coming to terms with a drug error.

Guided reflection

Use the following points to write a reflection for your PREP portfolio:

- Write about why this article is relevant to you and your practice;

- Identify the main points the article makes about drug errors;

- Outline anything new you have learnt about dealing with drug errors;

- Consider how you can use this information in your practice;

- Explain how you will follow up what you have learnt.



Nurses Role in Medication Administration

Last updated: Monday January 06, 2003

Much of nursing practice involves decisions about:

administration

effects

side effects of drugs

Implications for Nursing Practice

Dependent practice - by Prescription

Interdependent practice - MD and RN consult

Independent practice - nurse prepares and administers monitors for side effects patientteaching

Nurse is responsible for what, how, when, and how much is given

Must question orders that seem incorrect or inappropriate

Nursing Implications

Responsible for understanding:

expected effects

untoward effects

dosages and protocol to give

actions to take in event of untoward reaction

Nursing Implications

DRUGS ARE LETHAL WEAPONS

THERE IS A FINE LINE BETWEEN CORRECT DOSES AND LETHAL OR

TOXIC EFFECTS

Definitions

Pharmacokinetics-

What the body does to the drug

Pharmacodynamics-

What the drug does to the body

Medication orders



Prescription from M.D.

sometimes nurse practitioner (CRNP) or physician’s assistant (PA) both may need to be

co-signed by MD

Types of med orders

standing - until cancelled or d/c by agency policy or for particular symptoms

prn - as needed (e.g. for pain)

single order - once, at a certain time

stat - immediately; once only

Essential parts of med order

client name

date/time order written

name of drug (generic or brand)

dosage (metric or apothecary)o amount

o frequency

route

signature

Routes of Administration

oral

sublingual

buccal

rectal topical

transdermal

inhalation

Parenteral

subcutaneous

intramuscular

intradermal

intravenous

intraarterial

Medication Administration5 "rights"

client

medication

dosage

route

time



o within 1/2 hour

Safe medication administration

5 "rights"

3 checkso reach for container or unit dose packet

o right before pouring or opening

o as return container - BEFORE administering

Administering any meds

You prepare, you give.

give within 30 minutes of time ordered

identify client (check name band)

explain to client

if client questions drug or dose - STOP observe client take med

o per agency policy

o antacids, lozenges

document after giving (or refused)

monitor and evaluate client response

Administering oral meds

check if NPO, intact gag and swallow reflex position patient properly

provide straw as needed

crush or mix in food (e.g. applesauce) prn

Administering parenteral meds

Select appropriate size (guage) and length of needle

o guage - 18 thru 27

o length - 1/2 to 2 inches

Select appropriate size syringe

o 1 - 3 ml Use aseptic technique

Select appropriate site - IM, SQ, ID

Administering parenteral meds

Don disposable gloves

Cleanse site



Inject quickly - 900

Aspirate (not heparin, intradermal)

Inject medication

Dispose in puncture-resistant container without recapping

Record

Evaluate

IM Site Selection

Dorsogluteal (buttock)

Ventrogluteal (hip)

Vastus lateralis (lateral thigh)

Rectus femoris (anterior thigh)

Deltoid (arm)

Needleless Systems/Protected Needles

recessed IV connectors

blunt cannulas

needles sheathed in plastic guard

retractable needles

Measurement Systems

Apothecary

o Basic unit weight - grain (gr)

o Basic unit volume - minim (m) (@ drop)o 1 gr = 1 m = 1 drop

o written with Roman numeral gr ii

o Others: dram (z ) ounce pint, quart, gallon

Household



o drop (gtt) 1 minim

o tsp (t) 4-5 ml (z ) @ 60 gtts

o 3 tsp = T (15 ml)

o 2 T = 1 oz (30 ml)

o 1 c = 8 oz

Metric

o based on units of ten (decimal system)

o 3 basic units measurement

o length - meter (m or M; cm; mm)

o volume - liter (l or L; ml)

o weight - gram (g or Gm; mg)

Volume and Weight Equivalents

Basic principles of math

Roman numerals i, ii, iii, iv, v, x gr i, gr v 1/2 = ss

Fractions

Decimals based on tenths

o R of . < 1.0 (0.78)

o L of . > 1.0 (12.0)

o Multiply by 10s, 100s, 1000s - move decimal point

o Add or subtract keep decimals lined up

Ratio and Proportion

ratio - express relationship by division 1/3 or 1:3

proportion - 2 equal ratios 1/3 = 3/9 or 1:3::3:9

Product of means always = product of extremes

use to solve for x

2 = 8 2:4::8: x 4 x

2 x = 32

x =

What you KNOW What you NEED

DOSE HAVE :: DESIRED DOSE Quantity on hand Quantity to give



Rx: Demerol 75 mg IM stat

Have: Demerol 100mg/ml in vial


100 mg :1ml :: 75 mg : x ml ( 100 = 75 ) 1 x

100 x = 75

x = ml

Rx: Cardizem 90 mg po qd

Have: 60 mg / tab


60 mg :1 tab :: 90 mg : x tabs ( 60 = 90 ) 1 x

60 x = 90

x = tabs

Rx: Lasix 40 mg IV push stat

Have: 10 mg / ml


10 mg :1ml :: 40 mg : x ml ( 10 = 40 ) 1 x

10 x = 40

x = ml

Rx: Amoxicillin 250 mg po q 6h

Have: 500 mg/5cc


500 mg : 5 ml :: 250 mg : x ml ( 500 = 250 ) 5 x

500 x = 1250

x = ml



Converting between systems of measurement

Rx: ASA gr v po qd

Have: ASA 325 mg tabs

How many tablets will you give?

Use conversion factor - gr and mg Conversion factor?

1 gr = 65 mg (KNOW)

What you KNOW What you NEED

UNKNOWN/NEED ?

5 gr = x mg

What you KNOW What NEED TO KNOW

1 gr = 65 mg :: 5 gr = x mg

(1) x = (65) (5) x = 325 mg (There are 325 mg in 5 gr)

How many tablets will you give?

325 mg = 325 mg (5 gr) 1 tab x tabs

325 x = 325

x =

May need 2 steps

Rx: Lithium gr x po t.i.d.

Have: Lithium 300 mg/capsule

How many caps will you give? Conversion factor: 60 mg = 1 gr

60 mg : 1 gr :: x mg : 10 gr x = 600 mg (not caps)

NOW 300 mg : 1 cap :: 600 mg : x caps 300 x = 600 x = 2 caps

Drugs measured in Units

Insulin 100U/ml

Heparin 10-20,000U/ml

Penicillin 400-800,000U/ml

Rx: 5,000U Heparin sq q 12h

Have: 20,000 U/ml

Can use Desired X Amount Have



5,000U X 1ml = 20,000U

Give = 1 or .25 ml 4

Rx: 40U NPH Insulin sq q AM

Have: 100U/ml in vial (U-100; U-50)

Use U-100 syringe

D X Amt 40U X 1ml = 0.4 ml H 100U

OR ratio/proportion 100U:1ml :: 40U: x ml

100 x = 40

x = 0.4 ml

Drugs provided in powder form

Must be reconstituted for injection

Rx: aqueous penicillin G 500,000 U IM Have: 5,000,000 U in dry powder in vial

How many ml will you give?

TRICK QUESTION!!

You need to reconstitute - add diluent.

Follow manufacturer directions.

Reconstitution instructions:

Add for U/ml 18 ml 250,000 8 ml 500,000 3 ml 1,000,000

How much diluent will you add?

(sterile water,NaCl)

You want to give 500,000U per dose.

Add 8 ml diluent = 500,000 U/ml

KNOW = UNKNOWN/NEED

500,000 U = 500,000 U 1 ml x ml

500,000 x = 500,000



x = ml

IV fluids

MD orders type solution amount " time of infusion

medications to be added

to continuous infusion

to intermittent infusion

(IVPB)

as bolus dose

Calculating milliliters per hour

Rx: 1000 ml NSS to run over 6 hours

total volume = ml/hour total time in hours

1000 = 166.6 ml/hr 6

Round off to 167 ml/hr

Calculating Drops per Minute

Rx: Administer 1000 ml D5W every 8 hr. Drop factor is 15 gtt/min

total volume x drop factor = gtt/min total time (in minutes)

1000 ml x 15 = 15000 8 x 60 480

= 31.25 gtt/min

Round to 31 gtt/min

Common IV Drop Factors

Macrodrip 10gtt/ml 15 gtt/ml 20 gtt/ml

Microdrip 60 gtt/ml

Rx: Kefzol 1 g IVPB q 6 h

(Mix in 50 ml D5W. Infuse over 20 min.)

Drop factor is 20 gtt/ml



Kefzol supplied as 500mg/ml.

How many ml will you add to 50 ml bag?

500 mg = 1g

1 ml x ml

500 mg = 1000 mg

1 ml x ml

500 x = 1000

x = ml

How many drops per minute will you run the Kefzol so it is absorbed in 20 minutes?

50 ml X 20 (drop factor) = 20 (time in minutes)

1000 = 20

Run at 50 gtts/min

Tips from Errickson & Todd

Write out units of measurement; must appear in same order

e.g. 60 mg = 90 mg (60mg:1tab::90mg: x tabs) 1 tab x tabs

line up decimals

Re-check if odd answer e.g. 25 tablets !! Calculator only as good as your set-up

Names of drugs



Generic - assigned

Official - as listed

USP, NF

Chemical - describes composition

Trade or brand name

Hydrochlorthiazide

aspirin

acetylsalicylic acid

Bayer

Hydrodiuril

Classifications of Drugs

According to:

body system - cardiac

clinical indication/effect - antibiotic

composition - chemical

symptom relieved/purpose - relieve pain

Kinds of Drug Actions

Therapeutic effect - desired Side effect - secondary or unintended

therapeutic should outweigh side effect

Kinds of Drug Actions

Adverse effects (FDA MEDWATCH)

Iatrogenic disease

cumulative - drug level builds up drug tolerance- larger doses needed for same effect

idiosyncratic - unexpected, peculiar

(e.g. elderly)

drug allergy - minor to serious immune reaction



anaphylactic reaction - sudden, life-threatening

Drug Interactions

Combined effect of 2 or more drugs alters effect of one or both:

antagonistic/inhibiting effect - lesser

o antacids/milk with Tetracycline

synergistic/potentiating effect - greater

o e.g. alcohol and barbiturates

Demerol and Phenergan

Drug Standards

To predict effect based on consistency,

uniform quality

Pure Food and Drug Act (1906) - must be listed in

o US Pharmacopeia (USP)

o National Formulary (NF)

Drug Laws

Federal Food, Drug, Cosmetic Act (1938)

o extensive testing of new drugs

Comprehensive Drug Abuse Prevention

and Control Act (1970) (Controlled Substances Act)

o must have prescription for controlled substances:

narcotics, amphetamines, barbiturates, tranquilizer

Harrison Narcotic Act

o controlled substances must be kept in double-lock system

State Nurse Practice Acts

Prescriptive rights for NPs

Administering drugs IV push

Question and/or refuse to give incorrect or contraindicated order



Decimal Point Dangers

Rx: dexamethasone .10 mg IV q 12h x 72 h

Transcribed as 10 mg

Avoid error by:

writing as dexamethasone 0.1 mg don’t use "0" after decimal point if 1.0 mg - write "1 mg" instead

Variables Influencing Drug Actions

Weight

usually based on 70 KG person

sometimes BSA- especially children

sometimes on time mcg/kg/min

Gender

generally based on amount of body fat & H2O

fewer studies done on women - hormonal effects


Genetic factors

variations in enzymes to process meds

variations in amounts needed for therapeutic effects

Cultural factors

health beliefs can affect use of medications


Psychologic factors

expected response to medication

Clinical trials/research

compare effects of active drug vs placebos

only ethical place for placebos

Signed informed consent


Pathology

illness states or disease affects drug absorption

especially true in organs that metabolize drugs

o renal failure

o hepatic failure

Cachexia



o altered albumin levels


Environment

Surroundings may enhance or diminish expected effects of medications

Z-track Injection Method

Used for irritating medications

Prevents "tracking" through layers of tissue

Make sure needle is free of medication

(change needle or wipe off)

Questions ?



of Me d ic a t i on Admin i s t r a t i on wi th Nurs ing Impl i c a t i ons

1. Right Medication. The medication given was the medication ordered.

Nursing Responsibility: Check three times for safe administration. Read the medication administrationrecord (MAR) and compare thelabel of the medication against it. Check the expiration date of the

medication. If the dosage does not match the MAR, determine if youneed to do a math calculation. While preparing the medication, look at the medication label and check against the MAR. Recheck the label onthe container before returning to its storage place.

2

. Right Amount / Dose. The dose ordered is appropriate for the client.

Nursing Responsibility: Give special attention if the calculation indicates multiple pills/tablets or a largequantity of a liquid medication.This can be a cue that the math calculation may be incorrect. Double

check calculations that appear questionable.

Know the usual dosagerange of the medication. Question a dose outside of the usual dosage range.3. Right Patient/Client. Medication is given to the intended client.

nurse to useat least two client identifiers whenever

room number. Acce identification number, photograph, or other person-specific identifier. Check the clients identification band with each

administration of medication.

s with the same or similar last names are on the

nursing unit.

4. Right Route. Give the medication by the ordered route.

Nursing Responsibility: Make certain that the route is safe and appropriate for the client. Clients mayrequire physical assistance inassuming positions for intramuscular injections.5

. Right Time and Manner. Give the medication at the right frequency and at the time ordered according to agency policy.

Nursing Responsibility: Medication given within 30 minutes before or after the scheduled time are considered to meet the right

timestandard. The nurse should also check institutional policy concerning administration of medications.Hospitals often have standardized interpretations for abbreviations. The nurse must memorize and utilizestandard abbreviations in interpreting, transcribing, and

preventing and reporting drug administration errors

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