Medication Errors A Serious Topic Left Behind
- 1. Leslie Richard Healthcare Professional Director - Healthcare 360 Degree Infection prevention and control !1 STRENGTHENING NURSING PROFESSIONALS & MEDICATION ERRORss
- 2. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND !2 ● Healthcare 360 Degree was established in 2016 by a group of healthcare professionals with combined experience of over 108 years in Indian healthcare delivery. In under only 2 years , we have expanded to a team of over 12 members, all of who have significant experience across hospital functioning. ● Healthcare 360 Degree provides complete operations management to hospitals through an on-site team and a back end support of experts. Our services cover the entire gamut of hospital operations including Marketing, Operations , HR, quality, IT etc. By providing end to end solutions, we guide the client on a process driven and assured growth path. Healthcare 360 Degree An Overview
- 3. !3 • India’s Upcoming Most feasible & Demanded Healthcare Consultancy • Total 108 years of accumulative Healthcare experience • TEAM of young Ensusiastic healthcare professionals • First to come up with Zero Credit Recovery Concept for Hospitals • 2 years, 26280 hrs of unmatched healthcare consulting experience • Wide range of project mix from Hospital to Single Speciality Cardiology, Orthopedic, Oncology etc • 50+ National Healthcare Management Consulting Assignments and still going on • 20 + NABH Accreditation assignments • Thrive on continuous improvement in patient experience , Quality & Reducing Cost of Promotors / Owners. • Improvement in efficiency and safety by adopting a lean planning mechanism Creating a sustainable healthcare delivery model • Bridging the gap between cost and quality • Analysis of ROI through historical trends and future expectation • Renowned Medical College on our Panel . Healthcare 360 Degree OUR USP Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND
- 4. !4 • A medication error is 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 . • A medication error is ‘a failure in the treatment process that leads to or has the potential to lead to harm to the patient’. • Medication errors can be classified, invoking psychological theory, as knowledge- based mistakes, rule-based mistakes, action-based slips, and memory-based lapses. This classification informs preventive strategies. • A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND Medication Errors Administrative Errors
- 5. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND Know 5 “ R “ , before Administration A. Right Drug B. Right Route C. Right Time D. Right Patient E. Right date of Expiry Know 5 “ R “ , of Nurses A. Right Patients B. Right Drug C. Right Time D. Right Dose E. Right Route !5
- 6. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND • Knowledge based Being unaware of the interaction between warfarin (Blood Clots) and erythromycin (infections Treatment) • Rule based Prescribing oral treatment in a patient with dysphagia • Action based Being distracted, writing diazepam (Anxiety Disorder ) for diltiazem (Hypertension) Types of Medication Errors and Preventions !6
- 7. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND Types of Medication Errors and Preventions Prescribing errors - wherein the selection of a drug is incorrect based on the patient's allergies or other indications. Additionally, the wrong dose, form, quantity, route (oral vs intravenous), concentration, or rate of admission could be used. Omission errors , in which there is a failure to give a medication dose before the next one is scheduled. Wrong time errors , wherein a medication is given outside the predetermined interval from its scheduled time. Improper dosing errors , wherein a greater or lesser amount of a medication is delivered than is required to Wrong dose errors , wherein the correct dosage was prescribed, but the wrong dose was administered. Improper administration technique errors , such as administering a medication intravenously instead of orally. Wrong drug preparation errors , wherein a medication is incorrectly formulated (i.e., too much or too little diluting solution added when a medication is reconstituted). !7
- 8. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND Cause of Medication Errors & It’s Overcome Distraction : A nurse who is distracted may read "diazepam" (Muscular Relaxation) as "diltiazem." (Hypertension) The outcome is not insignificant-if diazepam is accidentally administered, Environment : A nurse who is chronically overworked can make medication errors out of exhaustion. Additionally, lack of proper lighting, heat/cold, and other environmental factors can cause distractions that lead to errors. Lack of knowledge/understanding : Nurses who lack complete knowledge about how a drug works, its various names (generic and brand), its side effects, its contraindications, etc. can make errors. Incomplete patient information : Lacking information about which medications a patient is allergic to, other medications the patient is taking, previous diagnoses, or current lab results can all lead to errors. Nurses who aren't sure should always ask the physician or cross-check with another nurse. Memory lapses : A nurse may know that a patient is allergic, but forget. This is often caused by distractions. Forgetting to specify a maximum daily dose for an "as required" drug is another example of a memory-based error. !8
- 9. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND PREVENTING MEDICATION ERRORS Nurses may not have the authority to make infrastructural changes, but they do have the power to suggest needed changes and take precautions to prevent medication errors, including the following: KNOW THE PATIENT This includes the patient's name, age, date of birth, weight, vital signs, allergies, diagnosis, and current lab results. If patients have a barcode armband-use it. The added administration times of using arm band systems have led some nurses to create potentially dangerous "workarounds" to avoid scanning barcodes. Don't make this potentially dangerous mistake- use all of the information at your disposal to ensure patient safety, and avoid shortcuts. KNOW THE DRUG Nurses need access to accurate, current, readily available drug information, whether the information comes from computerized drug information systems, order sets, text references, or patient profiles. If you have any questions or concerns about a drug, don't ignore your instincts-ask, even if the physician prescribed the wrong medication, the wrong dose, the wrong frequency, etc. Cause of Medication Errors & It’s Overcome !9
- 10. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND DOUBLE CHECK HIGH ALERT MEDICINES High-alert medicines such as heparin can have devastating consequences if not administered properly. A tragic case involving the death of three infant patients (Reputed Hospital - Delhi) after receiving massive heparin overdoses happened as a result of misleading packaging. Since this incident, the drug manufacturer now uses larger font sizes, tear-off cautionary labels, and different colors to distinguish drug doses.6 Medications often look alike and sound alike-this can be a source of errors. Double check high alert medications with another nurse to prevent accidental overdoses and other medication errors. DOCUMENT EACH DRUG ADMINISTERED Accurate documentation is essential and should include accurate recording of the drug information, the name of the drug, the dose, route, time, patient response, and any refusal of the drug by the patient. Cause of Medication Errors & It’s Overcome !10
- 11. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND !11
- 12. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND !12
- 13. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND Medication Errors is the third most common disease Leading to DEATH !13
- 14. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND To Avoid Medication Error and General Instruction ✓Always give medicine from a written order signed by a doctor. ✓Always check the expiry of a medicine before giving it to a patient. ✓Never give medicine on an empty stomach unless specified by the treating doctor. ✓Keep 5 “R” in mind – right drug, right dose, right patient, right time, and right route. ✓The nurse should know about the medication she is administering, it’s use contraindications a side effects. ✓Record the time of medicine given and put a signature. What to Do / PROCEDURE: ✓ Wash hands as per hand wash policy. ✓ Set up a tray. ✓ Check the written order in file. ✓ For liquids, shake the bottle well and after pouring the required amount, wipe the bottle w paper before closing the lid. ✓ Carry the tray to the patient. ✓ Recheck the identity of the patient by calling out his name. ✓ Explain the procedure to the patient. ✓ Give the medicine one by one and explain why it is given. ✓ Record the same. ✓ Replace the tray after washing and drying. !14
- 15. Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND NURSING PROTOCOL FOR INTRA MUSCULAR INJECTIONS GENERAL INSTRUCTIONS: ✓ Check the prescription of the physician before administering injection. ✓ Check the date of expiry of the drug ✓ Read the label and check the strength of the medication ✓ Use sharp needle of appropriate size to avoid undue discomfort ✓ Be sure patient is not sensitive to the drug ✓ Do a sensitivity test whenever required. ✓ Administer the drug by following 5 “R” Right patient Right drug Right time Right dose Right route ✓ Select the right needle for thin and obese patients. ✓ Do not use any drug which is discolored or has sediments. ✓ Alternate the site of injection each time to prevent irritation for allowing complete absorption. !15
- 16. !16 - Upgrade to Emerging Technologies - Training on equipment use and its interpretation - Using “smart” technology - Involving Nurses in Technology Design and Implementation - Interdisciplinary coordination: - Electronic Healthcare Records (EHR): - Pay-for-performance initiatives - Providing cordial environment - Giving them space for personal life - Represent Your Profession Well - Analyze your Potential Strengthening Nursing Professions & Empowering Nurses Strengthening Nursing Professionals & Medication Errors - An Important Aspect of Hospital LEFT BEHIND
- 17. !17
- 18. Leslie Richard Healthcare Professional Director - Healthcare 360 Degree Infection prevention and control !18 THANKS FOR YOUR PATIENCE