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

to occur. 1ea$th care providers have a responsi2i$it. to

+O, %* RiNCi LEs Of "D$iNistERiNG REsCRi+ED $EDiCiNEs (N$C, 200))

5here possi2$e the prescription must 2e 2ased on in#ormed consent, !ith the patient educated to the appropriate $eve$
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paediatric medi-cines are ca$cu$ated and administered, and c$inica$ areas that use $arge 8uantities o# contro$$ed drugs (Smith, '%%4).

Defining " #rug error

7here is a range o# opinion a2out !hat constitutes a drug error (36Shea, 1999) and nurses, pharmacists and doctors ma. not actua$$. agree on !hat the pr e-cise de#inition is. 7he Nationa$ Patient Sa#et. Agenc. uses the de#inition o# the :S Nationa$ Coordinating Counci$ #or Medication ;rror Reporting and Prevention <A medication error is an. preventa2$e event that ma. cause or $ead to inappropriate medication use or patient harm !hi$e the medication is in the con-tro$ o# hea$th pro#essiona$, patient or consumer6 (Smith, '%%4). -rug errors can inc$ude misca$cu$ation, over-dosing and underdosing (Preston, '004). 1o!ever, drug-re$ated incidents are rare$. a resu$t o# iso$ated thought$essness. 7he underpinning causes are o#ten comp$e4 and mu$ti#aceted, and nurses tend to vie! them as mu$tip$e-cause incidents (Preston, '%%4).

7he prescription must 2e c$ear$. !ritten !ith no room #or am2iguit. or vagueness and shou$d 2e signed 2. the person issuing the prescription
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Necessar. in#ormation a2out !eight and an. a$$ergies must 2e present !hen re$evant l 7he #ive Rs must 2e #o$$o!ed (+o4 ')
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A$$ detai$s a2out dose, generic or 2rand name, stated #orm, strength and timing, #re8uenc., route, and start and #inish dates must 2e c$ear
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9er2a$ orders shou$d 2e avoided and !here possi2$e #a4 or e-mai$ messages ta"en in pre#erence
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identi#. and minimise high-ris" areas or condi-tions, !hich inc$ude those !here

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N- 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. 5hen administering drugs it is im-portant to #o$$o! <the #ive Rs6 (+o4 ') (Preston, '%%4). Procedures shou$d 2e in p$ace and prescrip-tions c$ear$. !ritten in order to #aci$itate this. 9er-2a$ orders #or drugs shou$d not 2e accepted (NMC, '%%4), nor shou$d 2ad$. !ritten prescriptions. I# prescriptions are i$$egi2$e and instructions are vague the !ho$e s.stem is open to #ai$ure. Compu-ter generated prescriptions can he$p to so$ve some o# these pro2$ems 2ut the s.stem is not universa$ and has training imp$ications #or those using it. A$$ "no!n a$$ergies shou$d 2e c$ear$. document-ed and sta## shou$d 2e made a!are o# them and educated regarding appropriate actions. =no!n areas o# higher ris" inc$ude l Anaesthetics>
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P a e d i a t r i c s >
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KE/WORDs

Medication

r a p . >
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-rug error

Ris"

I 9 i n # u s i o n s >
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Chemotherap.> l Intravenous therap.. 7he main groups o# serious-ris" drugs are l Anticoagu$ants> l Anaesthetics>
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Intensi ve care> l

C h e m o t h e

M e t h o t

re4ate >l 3piate s> l Potassium ch$oride. In,ections in an. #orm come !ith their o!n set o# potentia$ ris"s (Smith, '%%4). Protoco$s shou$d 2e care#u$$. #o$$o!ed !ith high-ris" drugs. 7hese shou$d inc$ude c$ose monitoring o# patients and sta##, training o# sta##, and !here appropriate, !e$$maintained in#usion pumps. 7he environment !here drugs are prepared must 2e c$ean and !ith as #e! distractions as pos-si2$e. 3ut-o#date medicines must 2e disposed o# immediate$.. 5here there is am2iva$ence a2out a prescription it must a$!a.s 2e c$ari#ied and an. con#usion over ca$cu$ations must 2e chec"ed. 5hen patients move #rom one care setting to another a$$ documentation must 2e comp$ete and good communication is vita$ to #aci$itate continuit. o# care and ensure that supp$ies do not run out. Nurses must 2e vigi$ant in chec"ing ca$cu$ations and in identi#.ing an. short#a$$ in their " no!$edge. I# the. are in an. dou2t it is essentia$ to dou2$e-chec" !ith an appropriate$. 8ua$i#ied co$$eague. Nurses shou$d a$so "eep a2reast o# pharmaco$ogica$ deve$-opments and $earn to ca$cu$ate doses in di##erent circumstances, regard$ess o# e4terna$ pressures. Particu$ar care must 2e ta"en !ith medications re8uiring a so$ution to 2e mi4ed or invo$ving the use o# decima$ points. 7hese can 2e con#using, especia$$. i# there is pressure to thin" 8uic"$. or i# distractions or #atigue are #actored into the scenario.

7he human #actor shou$d a$so 2e considered. Peop$e ma"e mista"es, and a$$ hea$th pro#ession-a$s are prone to moments o# poor concentration and can miss something vita$. :n#ortunate$., in hea$th care the conse8uences o# this can 2e #ata$. Patients a$so need to 2e !e$$ in#ormed a2out an. medications the. are given and an. $i"e$. side-e##ects. Capa2$e patients shou$d 2e invo$ved in their treatment, !hi$e re$atives or carers can ta"e on this ro$e i# the patient is not a2$e to do so.

+O, 2& thE fi!E Rs Of DRuG "D$iNistR"tiON

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Right drug Right dose Right route Right time Right patient

Reporting of #rug errors

It is genera$$. 2e$ieved that the num2er o# report-ed drug errors is the <tip o# the ice2erg6 (1ac"e$ et a$, 199/) and that #ar more go unreported. ?ear, chie#$. o# management reprisa$ and the reaction o# co$$eagues, o#ten deters nurses #rom reporting in-cidents (Pape, '%%1). 1o!ever, it is essentia$ to 2e vigi$ant a2out reporting in order to identi#. and recti#. de#ective s.stems (-o1, '%%%). 7he NMC ('%%4) advocates thorough investigation o# a$$ er-rors and incidents at $oca$ $eve$. Near misses as !e$$ as actua$ errors need to 2e reported so the incident can 2e assessed and ana-$.sed and an. necessar. changes made to en-hance patient sa#et.. 7his is done under 2odies such as the NPSA and the Nationa$ Institute #or 1ea$th and C$inica$ ;4ce$$ence.

-he .i#er picture

As treatments 2ecome more comp$e4, tight contro$ and minimisation o# ris" 2ecome increasing$. im-portant. Reducing drug errors, near misses and incidents does not on$. concern hea$th pro#essiona$s and patients ) it is a matter o# concern #or govern-ments g$o2a$$., and sharing in#ormation ma. he$p countries to gain insight into patterns o# drug error and enhance prevention (Smith, '%%4). 1ea$th care providers a$so need ro2ust s.stems to assist nurses in minimising the incidence o# drug errors and in $earning #rom those that do occur.

f"cing up to " #rug error

Pro#essiona$s6 se$#-esteem can 2e 2ad$. a##ected 2. drug errors (Arndt, 1994) and a rea$ #ear o# negative conse8uences can de$a. the reporting o#

RefeRences
1ac"e$, R. et a$ (199/) 1o! nurses perceive medication errors. Nurse Management; '( 1, *1)*4. Ma.o, A .M., -uncan, -. ('%%4) Nurses6 perception o# medicine errors !hat !e need to "no! #or patient sa#et.. Journal of Nurse Care Quality> 19 *, '%9)'1(. NMC ('%%4) Guidelines for the Administration of Medicines. London NMC. 36Shea, ;. (1999) ?actors contri2uting to medication errors a $iterature revie!. Journal of Clinical Nursing; 0 &, 49/)&%4. Pape, 7.M. ('%%1) Searching #or the #ina$ ans!er #actors contri2uting to medica$

administration errors. Journal of Continuing Education in Nursing; *' 4, 1&')1/%.

7his artic$e has 2een dou2$e-2$ind peerrevie!ed. ?or re$ated artic$es on this su2,ect and $in"s to re$evant !e2sites see !!!.nursingtimes.net

N- 19 March '%1* 9o$ 1%1 No ** ....nursingti$es.net

''

KNOWLED

Refe Renc es
Parish, C. ('%%*) Comp$acenc. to 2$ame #or trans#usion mista"es. Nursing tandard; 1( 4&, 0. Preston, R.M. ('%%4) -rug errors and patient sa#et. the need #or a change in practice. !ritish Journal of Nursing; 1* ', (') (0. Smith, @. ('%%4) !uilding a afer N" for Patients# $m%ro&ing Patient afety. 'e%artment of "ealth Chief Pharmacist(s )e%ort. London Cro!n. 5a"e#ie$d, -.S. et a$ (199/) Perceived 2arriers in reporting medication administration error. !est Practices and !enchmar*ing in "ealthcare;

1 4, 191) 19(. 5i$"inson, @. (1999) Imp$ementing re#$ective practice. Nursing tandard; 1* '1, */) 4%.

errors (5a"e#ie$d et a$, 199/). 1o!ever, a de$a. in reporting can have #ar-reaching conse8uences. 7he #irst consideration must 2e #or the patient and !hether an. serious harm has 2een done and !hat remedia$ actions are re8uired. 1o!ever, !hen hea$th pro#essiona$s rea$ise the. have made an error the. ma. panic and tr. to cover up the in-cident. It is important #or them to rea$ise the. have not committed a crime ) the. have made a mis-ta"e. ;ven i# it !as 2orn o# comp$acenc. the rea-sons 2ehind the error can usua$$. 2e traced. It is essentia$ to 2e as accurate as possi2$e !hen reporting an incident. 3mitting in#ormation out o# #ear, rea$ or perceived, does not he$p the $ong-term outcome. I# s.stemic reasons $ed to the error and these are not identi#ied the error !i$$ recur in the #uture. I# an. #acts are omitted an incorrect picture o# !hat happened ma. emerge (-o1, '%%%). It is essentia$ #or hea$th pro#essiona$s to o2tain support i# the. have made a drug error. 7his ma. 2e #rom $ine managers, union representatives or occupationa$ hea$th !or"ers. 7a$"ing through an error stops it #rom d!e$$ing in the mind, !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$o!ing it out o# proportion. 5hi$e it is important to comp$ete statements and

ac"no!$edge the incident has happened, it must not 2e a$$o!ed to dominate the person6s $i#e. It ma. 2e appropriate #or the person to ta"e a #e! da.s o# sic" $eave i# the incident has caused enough stress a##ect her or his a2i$it. to practise sa#e$.. 1o!ever, e4cept in the most e4treme situations, 2eing at !or" and putting the incident in the past is the 2est !a. to cope !ith the a#termath o# a drug error.

1o!ing on
-uring the process o# #acing the conse8uences o# a drug error, "eeping a re#$ective ,ourna$ can 2e a use#u$ se$#he$p too$ (5i$"inson, 1999). 5riting do!n detai$s o# the incident, the circumstances

cathar-tic and !i$$ he$p put it into perspective. It can a$so 2e he$p#u$ as an aide memoire !hen reporting to an. investigations. It can 2e he$p#u$ to l 7he nurse must have the right $eve$ re#$ect on a range o# 8uestions o# competence and "no!$edge o# the (+en,amin, '%%*), such as drug, side-e##ects and patient6s l Cou$d the error 2e attri2uted to a medica$ histor. l 7he #ive Rs must 2e adhered to possi2$e #ai$-ure in the s.stemA l ;nvironmenta$ sa#et. and correct storag l Cou$d it have 2een preventedA l 5ere a$$ the appropriate l 7he medicine must not 2e out o# date actions ta"enA l 5hat changes l Ris"s associated !ith the drug, 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. precautions educationA l Is the error ta"en $i"e$. to recurA l An. 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"$. and e##icient$. $imits the person !ho !rote the prescription damage and restores trust and l A$$ documentation must 2e correct$. con#idence in the c$inica$ area. It is comp$eted !hen the drug has 2een important to "eep the situation in given perspective and not a$$o! it to 2ecome 2$o!n out o# proportion. I# managed proper$., it !i$$ 2e treated as an that contri2uted to it, un#ortunate inci-dent and !i$$ not persona$ reactions to the a##ect career opportunities. mista"e and #ee$ings arising #rom it, can 2e

+O, '* CONsiDER"tiONs iN2 thE "D$iNistR"tiON Of2 $EDiCiNEs

Conclusion

Gui#e# reflection
3se the follo.ing points to .rite " reflection for /our RE portfolio&

5rite a2out !h. this artic$e is re$evant to .ou and .our practice>
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Identi#. the main points the artic$e ma"es a2out drug errors>
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3ut$ine an.thing ne! .ou have $earnt a2out dea$ing !ith drug errors>
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Consider ho! .ou can use this in#ormation in .our practice>

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;4p$ain ho! .ou !i$$ #o$$o! up !hat .ou have $earnt.

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Bood communication, c$arit. and vigi$ance are vi-ta$ !henever drugs are 2eing administered. Medi-cine administration is a s"i$$ed 2ut potentia$$. 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. 5hen underta"ing the administration o# medi-cines nurses must 2e !i$$ing to ta"e responsi2i$it. #or their actions and recti#. an. short#a$$s in their "no!$edge. 1o!ever, #or this to happen there needs to 2e a cu$ture in !hich nurses can report errors or near misses !ithout #ear o# reprisa$. Incidents shou$d 2e turned into situations #rom !hich $essons are $earnt and progress is made. n

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University of Perpetual Help System Dalta Alabang Zapote Road, Pamplona, Las Pi as !ity !"LL#$# "% &URS'&$

JOURNAL ABOUT JURICE-PRUDENCE CASE IN NURSING Preventing and Reporting Drug Administration Errors

Submitted by: Quimb , S! "t S. BSN #B $%&. S'b%e(e) C*i"i+ * I"&t%u+t'%

REACTION: I understand more about the importance of administering medication with this journal. It s an e!e opener not just for me but for m! future colleague as well. As "uoted in the abo#e conclusion $%ood communication& clarit! and #igilance are #ital whene#er drugs are being administered. 'edicine administration is a s(illed but

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. *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. +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. Incidents should be turned into situations from which lessons are learnt and progress is made., -eing a student nurse and soon to be a license nurse I will be #er! #igilant and super e.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.

Reference: http://www.nursingtimes.net/0ournals/1234/24/35/r/"/t/2627389re#enting:and:reporting:drug: administration:errors.pdf