![Verbal and Telephone Orders
Telephone Order Procedure
1st Nurse records, 2nd Nurse “Reads Back”
“Read Back” – NOT repeat back
Spell out 1- 5 for 15 [confused with 50]
NOT allowed for the following:
Chemotherapeutic agents
Parenteral nutrition
Initiation of:
Epidural medications
Patient Controlled Analgesia / narcotic drips
Parenteral pressor agents
Parenteral skeletal muscle relaxants](https://image.slidesharecdn.com/2-250624063104-9fb9cf0f/85/2-Overview-of-Medication-Errors-2018-pdf-18-320.jpg)
2.-Overview-of-Medication-Errors-2018.pdf
- 1. Basic Medication Safety (BMS) Certification Course King Saud bin Abdulaziz University for Health Sciences Ministry of National Guard – Health Affairs Overview of Medication Errors
- 2. Learning Objectives Identify Human Factors associated with medication errors Explain the concept of a Just Culture Review definitions related to medication safety Discuss the impact of latent failures on medication safety
- 3. To Err is Human
- 4. Occupational injuries cause 6,000 deaths per year 7,000 deaths yearly are caused by medication errors1 1Institute of Medicine (IOM) USA, 1999
- 5. Human Factors – Confront Two Myths If people try hard enough they will not commit medication errors. If we punish people when they make an error they will make fewer of them. The perfection myth: The punishment myth:
- 6. Human Factors – Error Types Rule & knowledge based errors arise when a situation is misinterpreted or a rule is misapplied Errors resulting from intended deviation from accepted standards, procedure and rules Unintended Actions (Right idea, wrongly actioned) Intended Actions Lapses Slips Errors in performance of a skill based behaviour, typically occur when attention is diverted Mistakes (wrong idea) Violation (rule breaking) Unsafe actions
- 7. Human Error Console At-Risk Behavior Coach Reckless Behavior Discipline Product of Our Current System Design and Behavioral Choices Manage through changes in: • Choices • Processes • Procedures • Training • Design • Environment A Choice: Risk Believed Insignificant or Justified Manage through: • Removing incentives for at-risk behaviors • Creating incentives for healthy behaviors • Increasing situational awareness Conscious Disregard of Substantial and Unjustifiable Risk Manage through: • Remedial action • Punitive action The Three Behaviors
- 8. 1436-05 Just / Accountabillity Culture Just Culture / Culture Of Accountability Punitive Culture • Before the 1990s • Frontline workers were afraid to report their own errors or those of a colleague • Missed enormous opportunities to learn about Errors • Little insight into System-based causes Blame-Free Culture •By the mid 1990s •Supported a "no- blame" response to errors •Unsafe acts were the result of mental slips or lapses, or honest mistakes •Fails to tackle individuals who make unsafe / reckless behavioral choices Just Culture • NEW • Recognize that humans are imperfect so errors will and can happen to anyone • Staff are encouraged (even rewarded) for reporting errors • There is a well- established system of accountability • High insight into System-based causes
- 9. Adverse Drug Events (ADEs) Medication Error Near Miss / Close Call Actual Medication Error Adverse Drug Reaction (ADR)
- 10. Definitions Adverse Drug Event (ADE) An injury from a drug-related intervention, and can include Adverse Drug Reaction and can result from errors in prescribing, dispensing and administration. Adverse Drug Reaction (ADR) A response to a medicinal product which is noxious and unintended and which occurs at doses normally used for the prophylaxis, diagnosis or therapy of disease or for restoration, correction or modification of physiological function. (APP 1434-07 Adverse Drug Events)
- 11. Definitions Medication Error Medication Error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (ISMP, ASHSP, NCC MERP). Significant medication errors are all medication errors. (APP 1434-07 Adverse Drug Events)
- 12. Definitions Near Miss (Close Call) An event, situation, or error that took place but was captured BEFORE reaching the patient. Example: The wrong drug was dispensed by pharmacy, and a nurse caught the error before it was administered to the patient. Hazardous situations refers to circumstances or events that have the capacity to cause error (e.g., confusion over LASA drugs or similar packaging). Defective Medicine It is a medicine where the product presentation and quality is not in accordance with regulation and professional standards. (National Patient Safety Agency, UK) (APP 1434-07 Adverse Drug Events)
- 13. Definitions Latent Failure (hidden / dormant errors) Refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. (Agency for Healthcare Research and Quality) Environmental Factors (e.g. Noise, poor light, etc.) Technology Factors Lack of and / or complex policies and procedures Communication Factors dentification ituation ackground ssessment ecommendation APP 1435-07 Patient Care Handover and Verbal/Telephone Communication
- 14. Risk Exists All Around Us
- 15. Prescribing Transcribing Dispensing Administering Prescribing Transcribing Dispensing Administering Potential For Harm (1) (Rate per 100 patients) 63.69 0.28 0.28 3.37 Errors NOT Intercepted (ADE) (2) 84% High incidence for ADEs due to medication administration errors justify the need to target interventions to prevent these errors in a hospital setting. (1) Qual Safe Health Care 2010; 19:e30 doi:10.1136/qshc.2008.031179 (2) BMJ Qual Saf 2012;21:933-938 Doi:10.1136/bmjqs-2012-000946 Errors In Medication Use Process
- 16. Swiss Cheese Model James Reason, 1991 Patient receives wrong drug Fatigue & Stress Poor Lighting, Temperature & Noise Lack of Training Programs (Competencies & Orientation)
- 17. Verbal and Telephone Orders Why Standardize Verbal / Telephone Orders? Inherently problematic: Different accents and limited short-term memory. When do you take a telephone order? Emergent situation Urgent situation: The prescribing practitioner has determined that the patient is in need of a medication within a specific time period and he / she is unable to physically enter the order in the patient's clinical record due to his / her physical location. APP 1429-03 Prescribing and Dispensing Medication Guidelines
- 18. Verbal and Telephone Orders Telephone Order Procedure 1st Nurse records, 2nd Nurse “Reads Back” “Read Back” – NOT repeat back Spell out 1- 5 for 15 [confused with 50] NOT allowed for the following: Chemotherapeutic agents Parenteral nutrition Initiation of: Epidural medications Patient Controlled Analgesia / narcotic drips Parenteral pressor agents Parenteral skeletal muscle relaxants
- 19. System Focused Thinking Humans are imperfect Accept that errors will occur Focus on the system, not the people