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SPL

KNOWLED

CLINICAL
Preventing and reporti ng drug administration err ors
-o1.

Author Chloe Copping, RGN, is practice nurse, +uc"den Surger., Cam2ridgeshire. AbstrAct Copping, C. (2005) re!enting "n# reporting #rug "#$inistr"tion errors. Nursing Times; %0%& '', '2(')* Registered nurses are accounta2$e #or their actions and omissions !hen administering an. medi-cines . 1o!ever, the increasing pressures and demands p$aced on nurses can render them more prone to ma"ing drug errors. Critica$ incidents must 2e turned into positive situations , #rom !hich $essons are $earnt and progress made. An. nurse !ho has made a drug error "no!s ho! stress#u$ this situation can 2e. Registered nurses are accounta2$e #or their actions and omissions !hen administering an. medicines and must ta"e responsi2i$it. #or an. errors the. ma"e. 1o!ever, the increasing demands p$aced on nurses can render them more prone to drug errors. 3ver!or" can a##ect concentration and competence and this can 2e e4acer2ated 2. erratic !or"ing hours and stress, !hi$e comp$acenc. can a$so $ead to mista"es (Parish, '%%*). 5hi$e nurse #atigue is a common$. cited cause o# drug errors, others inc$ude i$$egi2$e ph.sicians6 hand!riting and distractions (Ma.o and -uncan, '%%4). In its guide$ines #or the administration o# medicines, the NMC ('%%4) out$ines the in#ormation a prescription must contain #or sa#e and correct drug administration and gives c$ear princip$es #or prescri2ing medicines (+o4 1). I# the prescription is c$ear and accurate, errors are $ess $i"e$.

RefeRence s
Arndt, M. (1994) Medication errors. Research into practice ho! drug mista"es a##ect se$#-esteem. Nursing Times; 9% 1&, '()*%. +en,amin, -.M. ('%%*) Reducing medication errors and increasing patient sa#et. a stud. in c$inica$ pharmaco$og.. Journal of Clinical Pharmacology; 4* (, (/0) (0*. -epartment o# 1ea$th ('%%%) An Organisation With a Memory. London

over-dosing and underdosing (Preston. 7he underpinning causes are o#ten comp$e4 and mu$ti#aceted. 5hen administering drugs it is im-portant to #o$$o! <the #ive Rs6 (+o4 ') (Preston.stem is open to #ai$ure. patient or consumer6 (Smith.. strength and timing. cause or $ead to inappropriate medication use or patient harm !hi$e the medication is in the con-tro$ o# hea$th pro#essiona$. agree on !hat the pr e-cise de#inition is. 7he Nationa$ Patient Sa#et. %* RiNCi LEs Of "D$iNistERiNG REsCRi+ED $EDiCiNEs (N$C. nor shou$d 2ad$. to +O. 1999) and nurses. uses the de#inition o# the :S Nationa$ Coordinating Counci$ #or Medication . and minimise high-ris" areas or condi-tions.rror Reporting and Prevention <A medication error is an. !ritten prescriptions. !ith the patient educated to the appropriate $eve$ l paediatric medi-cines are ca$cu$ated and administered. Compu-ter generated prescriptions can he$p to so$ve some o# these pro2$ems 2ut the s. and start and #inish dates must 2e c$ear l 9er2a$ orders shou$d 2e avoided and !here possi2$e #a4 or e-mai$ messages ta"en in pre#erence l identi#. 1o!ever. document-ed and sta## shou$d 2e made a!are o# them and educated regarding appropriate actions.net N. or vagueness and shou$d 2e signed 2. route.> l Intravenous therap. in#ormation a2out !eight and an. a$$ergies must 2e present !hen re$evant l 7he #ive Rs must 2e #o$$o!ed (+o4 ') l A$$ detai$s a2out dose..stem is not universa$ and has training imp$ications #or those using it. preventa2$e event that ma. a resu$t o# iso$ated thought$essness. !hich inc$ude those !here '2 .nursingti$es. Agenc. '004). -rug errors can inc$ude misca$cu$ation. =no!n areas o# higher ris" inc$ude l Anaesthetics> l P a e d i a t r i c s > l KE/WORDs n Medication n r a p . Procedures shou$d 2e in p$ace and prescrip-tions c$ear$. '%%4). drug-re$ated incidents are rare$.. 7he main groups o# serious-ris" drugs are l Anticoagu$ants> l Anaesthetics> l Intensi ve care> l C h e m o t h e M e t h o t .to occur. 1ea$th care providers have a responsi2i$it. A$$ "no!n a$$ergies shou$d 2e c$ear$. #re8uenc. '%%4).. > l -rug error n Ris" I 9 i n # u s i o n s > l Chemotherap. not actua$$. and c$inica$ areas that use $arge 8uantities o# contro$$ed drugs (Smith.19 March '%1* 9o$ 1%1 No ** Ris0 re#uction A num2er o# steps can 2e ta"en to reduce the ris" o# drug errors.. !ritten in order to #aci$itate this. the person issuing the prescription l Necessar. '%%4). 200)) 5here possi2$e the prescription must 2e 2ased on in#ormed consent. I# prescriptions are i$$egi2$e and instructions are vague the !ho$e s. 7he prescription must 2e c$ear$. and nurses tend to vie! them as mu$tip$e-cause incidents (Preston. pharmacists and doctors ma. generic or 2rand name. !ritten !ith no room #or am2iguit. stated #orm. Defining " #rug error 7here is a range o# opinion a2out !hat constitutes a drug error (36Shea. '%%4). '%%4). 9er-2a$ orders #or drugs shou$d not 2e accepted (NMC.

and a$$ hea$th pro#ession-a$s are prone to moments o# poor concentration and can miss something vita$. de#ective s. 7he NMC ('%%4) advocates thorough investigation o# a$$ er-rors and incidents at $oca$ $eve$.sed and an. necessar. 2& thE fi!E Rs Of DRuG "D$iNistR"tiON l l l l l Right drug Right dose Right route Right time Right patient Reporting of #rug errors It is genera$$. 7hese shou$d inc$ude c$ose monitoring o# patients and sta##. !e$$maintained in#usion pumps. medications the. In. $i"e$. especia$$. #o$$o!ed !ith high-ris" drugs. '%%%). chie#$.ing an.. in hea$th care the conse8uences o# this can 2e #ata$. i# there is pressure to thin" 8uic"$. drug errors (Arndt. it is essentia$ to 2e vigi$ant a2out reporting in order to identi#. 199/) and that #ar more go unreported. he$p countries to gain insight into patterns o# drug error and enhance prevention (Smith. o# care and ensure that supp$ies do not run out.i#er picture As treatments 2ecome more comp$e4. -he . 5hen patients move #rom one care setting to another a$$ documentation must 2e comp$ete and good communication is vita$ to #aci$itate continuit. Particu$ar care must 2e ta"en !ith medications re8uiring a so$ution to 2e mi4ed or invo$ving the use o# decima$ points. +O. are given and an. con#usion over ca$cu$ations must 2e chec"ed. :n#ortunate$.re4ate >l 3piate s> l Potassium ch$oride. training o# sta##. Nurses must 2e vigi$ant in chec"ing ca$cu$ations and in identi#. the reporting o# . near misses and incidents does not on$. are in an. Capa2$e patients shou$d 2e invo$ved in their treatment. Near misses as !e$$ as actua$ errors need to 2e reported so the incident can 2e assessed and ana-$. dou2t it is essentia$ to dou2$e-chec" !ith an appropriate$. changes made to en-hance patient sa#et. 8ua$i#ied co$$eague. '%%4).4ce$$ence. o#ten deters nurses #rom reporting in-cidents (Pape. regard$ess o# e4terna$ pressures. 3ut-o#date medicines must 2e disposed o# immediate$. a##ected 2. Reducing drug errors. 1o!ever. I# the. 7he environment !here drugs are prepared must 2e c$ean and !ith as #e! distractions as pos-si2$e. concern hea$th pro#essiona$s and patients ) it is a matter o# concern #or govern-ments g$o2a$$.s 2e c$ari#ied and an. im-portant.. tight contro$ and minimisation o# ris" 2ecome increasing$. '%%4).stems (-o1. '%%1). Peop$e ma"e mista"es. 7hese can 2e con#using..ections in an. f"cing up to " #rug error Pro#essiona$s6 se$#-esteem can 2e 2ad$. 2e$ieved that the num2er o# report-ed drug errors is the <tip o# the ice2erg6 (1ac"e$ et a$. Protoco$s shou$d 2e care#u$$. 7he human #actor shou$d a$so 2e considered. short#a$$ in their " no!$edge. and sharing in#ormation ma. ?ear. side-e##ects. 1ea$th care providers a$so need ro2ust s. and !here appropriate. 7his is done under 2odies such as the NPSA and the Nationa$ Institute #or 1ea$th and C$inica$ . and recti#. or i# distractions or #atigue are #actored into the scenario. Patients a$so need to 2e !e$$ in#ormed a2out an. #orm come !ith their o!n set o# potentia$ ris"s (Smith. !hi$e re$atives or carers can ta"e on this ro$e i# the patient is not a2$e to do so. o# management reprisa$ and the reaction o# co$$eagues. 5here there is am2iva$ence a2out a prescription it must a$!a.. Nurses shou$d a$so "eep a2reast o# pharmaco$ogica$ deve$-opments and $earn to ca$cu$ate doses in di##erent circumstances. 1994) and a rea$ #ear o# negative conse8uences can de$a.stems to assist nurses in minimising the incidence o# drug errors and in $earning #rom those that do occur.

Nurse Management. A . 0 &. 1o!ever. '%%%).19 March '%1* 9o$ 1%1 No ** . 1o!ever. 5hi$e it is important to comp$ete statements and . @. It is essentia$ #or hea$th pro#essiona$s to o2tain support i# the. -. . 5a"e#ie$d.net '' KNOWLED Refe Renc es Parish. 191) 19(.nursingti$es. 0. have made a mis-ta"e. ('%%1) Searching #or the #ina$ ans!er #actors contri2uting to medica$ administration errors. 7a$"ing through an error stops it #rom d!e$$ing in the mind. does not he$p the $ong-term outcome. Ma.nursingtimes. . 7he #irst consideration must 2e #or the patient and !hether an. ('%%4) -rug errors and patient sa#et. union representatives or occupationa$ hea$th !or"ers. Pape. -. (1999) Imp$ementing re#$ective practice.. 7his ma. It is important #or them to rea$ise the. 1* '1.. 2e traced. 1* '. ma. London Cro!n. the rea-sons 2ehind the error can usua$$. Nursing tandard. R.ven i# it !as 2orn o# comp$acenc. 7his artic$e has 2een dou2$e-2$ind peerrevie!ed. Preston.. It is essentia$ to 2e as accurate as possi2$e !hen reporting an incident. '%9)'1(. rea$ or perceived. have made a drug error.M. (1999) ?actors contri2uting to medication errors a $iterature revie!.. @.o. !est Practices and !enchmar*ing in "ealthcare. a de$a. 3mitting in#ormation out o# #ear. ('%%*) Comp$acenc. have made an error the. Smith. R. emerge (-o1. *' 4. Nursing tandard. C. 2e #rom $ine managers. -uncan. 1&')1/%.M. to 2$ame #or trans#usion mista"es. panic and tr.. Journal of Continuing Education in Nursing.S. 'e%artment of "ealth Chief Pharmacist(s )e%ort. !hen hea$th pro#essiona$s rea$ise the. et a$ (199/) Perceived 2arriers in reporting medication administration error. 36Shea. 49/)&%4. #acts are omitted an incorrect picture o# !hat happened ma. ('%%4) !uilding a afer N" for Patients# $m%ro&ing Patient afety. (') (0. I# an.M. */) 4%. serious harm has 2een done and !hat remedia$ actions are re8uired.RefeRences 1ac"e$.ect and $in"s to re$evant !e2sites see !!!. et a$ (199/) 1o! nurses perceive medication errors. Journal of Clinical Nursing. 1( 4&. ('%%4) Nurses6 perception o# medicine errors !hat !e need to "no! #or patient sa#et. 7.. *1)*4. !ritish Journal of Nursing. 199/).net N. I# s. London NMC. Journal of Nurse Care Quality> 19 *. 5i$"inson.stemic reasons $ed to the error and these are not identi#ied the error !i$$ recur in the #uture. NMC ('%%4) Guidelines for the Administration of Medicines. in reporting can have #ar-reaching conse8uences. !hi$e admitting to someone e$se that it happened he$ps to put the matter in perspective and can prevent the hea$th pro#essiona$ concerned #rom 2$o!ing it out o# proportion. have not committed a crime ) the. 1 4. '( 1. the need #or a change in practice. errors (5a"e#ie$d et a$. to cover up the in-cident. ?or re$ated artic$es on this su2.

an. to practise sa#e$. "eeping a re#$ective . the main points the artic$e ma"es a2out drug errors> l 3ut$ine an.. '%%*). #or their actions and recti#. and correct storag l Cou$d it have 2een preventedA l 5ere a$$ the appropriate l 7he medicine must not 2e out o# date actions ta"enA l 5hat changes l Ris"s associated !ith the drug. l Bood communication. c$arit.ou !i$$ #o$$o! up !hat . 1o!ever.ourna$ can 2e a use#u$ se$#he$p too$ (5i$"inson.our practice> l . to cope !ith the a#termath o# a drug error. It can 2e he$p#u$ to l 7he nurse must have the right $eve$ re#$ect on a range o# 8uestions o# competence and "no!$edge o# the (+en. it must not 2e a$$o!ed to dominate the person6s $i#e. 1o!ever. the circumstances cathar-tic and !i$$ he$p put it into perspective.thing ne! .s o# sic" $eave i# the incident has caused enough stress a##ect her or his a2i$it. It can a$so 2e he$p#u$ as an aide memoire !hen reporting to an. Incidents shou$d 2e turned into situations #rom !hich $essons are $earnt and progress is made. con#usion must 2e c$ari#ied !ith a -ea$ing !ith the e##ects o# a drug suita2$e practitioner and !here possi2$e error 8uic"$.ou can use this in#ormation in . side-e##ects and patient6s l Cou$d the error 2e attri2uted to a medica$ histor. 2eing at !or" and putting the incident in the past is the 2est !a. con#idence in the c$inica$ area.ou have $earnt.stemA l .4p$ain ho! . 1999).ou and . 5riting do!n detai$s o# the incident. and e##icient$. It is comp$eted !hen the drug has 2een important to "eep the situation in given perspective and not a$$o! it to 2ecome 2$o!n out o# proportion.ou have $earnt a2out dea$ing !ith drug errors> l Consider ho! . Medi-cine administration is a s"i$$ed 2ut potentia$$. c$inica$ need to 2e madeA l Is there a need #or #urther setting or c$ient group must 2e ac"no!$edged and necessar. dan-gerous procedure and it is essentia$ to 2e a$ert to possi2$e pit#a$$s and to #o$$o! guide$ines in order to minimise the ris"s.ing points to . $imits the person !ho !rote the prescription damage and restores trust and l A$$ documentation must 2e correct$. It ma. '* CONsiDER"tiONs iN2 thE "D$iNistR"tiON Of2 $EDiCiNEs Conclusion Gui#e# reflection 3se the follo. precautions educationA l Is the error ta"en $i"e$. such as drug. investigations.. 1o!ing on -uring the process o# #acing the conse8uences o# a drug error. mista"e and #ee$ings arising #rom it.amin.ac"no!$edge the incident has happened.rite " reflection for /our RE portfolio& 5rite a2out !h.nvironmenta$ sa#et. 2e appropriate #or the person to ta"e a #e! da. and vigi$ance are vi-ta$ !henever drugs are 2eing administered. n . can 2e +O. e4cept in the most e4treme situations. this artic$e is re$evant to . un#ortunate inci-dent and !i$$ not persona$ reactions to the a##ect career opportunities. #or this to happen there needs to 2e a cu$ture in !hich nurses can report errors or near misses !ithout #ear o# reprisa$. 5hen underta"ing the administration o# medi-cines nurses must 2e !i$$ing to ta"e responsi2i$it. short#a$$s in their "no!$edge. l 7he #ive Rs must 2e adhered to possi2$e #ai$-ure in the s.our practice> l Identi#. it !i$$ 2e treated as an that contri2uted to it. to recurA l An. I# managed proper$.

N. 2.2 nu 2rsi 2 2n 2 2g 2 2t 22 i$ 2e 22s 222 .2 n 2e 22t 2 . 2 22 ..19 March '%1* 9o$ 1%1 No ** 2 .

It s an e!e opener not just for me but for m! future colleague as well. 'edicine administration is a s(illed but . BSN #B $%&.University of Perpetual Help System Dalta Alabang – Zapote Road. Pamplona. S! "t S. Las Pi as !ity !"LL#$# "% &URS'&$ JOURNAL ABOUT JURICE-PRUDENCE CASE IN NURSING “Preventing and Reporting Drug Administration Errors” Submitted by: Quimb . As "uoted in the abo#e conclusion $%ood communication& clarit! and #igilance are #ital whene#er drugs are being administered. S'b%e(e) C*i"i+ * I"&t%u+t'% REACTION: I understand more about the importance of administering medication with this journal.

Reference: http://www. -eing a student nurse and soon to be a license nurse I will be #er! #igilant and super e.pdf .nursingtimes. +owe#er& for this to happen there needs to be a culture in which nurses can report errors or near misses without fear of reprisal. *hen underta(ing the administration of medicines nurses must be willing to ta(e responsibilit! for their actions and rectif! an! shortfalls in their (nowledge.net/0ournals/1234/24/35/r/"/t/2627389re#enting:and:reporting:drug: administration:errors.potentiall! dangerous procedure and it is essential to be alert to possible pitfalls and to follow guidelines in order to minimi)e the ris(s. Incidents should be turned into situations from which lessons are learnt and progress is made..tra careful in administering medication because medication error can t just harm the life of m! future patient but m! career and license are also at sta(e.