BeyondtheFiveRightsof

MedicationAdministration
IMSN2011
Presentedby
MichelleMandrack,RN,MSN
ISMP
Aremedication
administration
errorsreallythat
bad?
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ErrorsintheMedicationUseProcess
Prescribing Transcribing Dispensing Administering
33%
2%
33%
Leape,etal.,1995
.
Errors 39%
12% 11%
38%
48%
Harm
28% 11% 10%
51%
Intercepted
ATimeHonoredTradition
Ifthenursehadonlyfollowedthefive
rights
Mistakenassumptionisthatthefiverights
isanerrorproofstrategy!
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5
MedicationAdministrationErrors
Medicationadministrationaccountsforuptoone
thirdofnursestime
Mostofthetime=huntingandgathering
34% 38%oferrorsoriginateintheadministration
phaseofthemedicationuseprocess,andfeware
intercepted
Overall,nursescientistsarenoticeablyabsentfrom
investigationofmedicationadministrationerrors

Bates,etal.,1995;Keohane,etal.,2008;Leape,etal.,1995;Pepper,1995
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IVMedicationErrors
IVmedicationsareassociatedwith54%of
potentialADEsandincreasedriskofharm
DrugsadministeredIVhaveimmediatebioavailability
Manyhighalert"drugs,whichhaveanarrowtherapeutic
range,aregivenbyinfusion
Recenthighprofilereportsofinjuryand
deathhavecreatednewsenseofurgency
Cohen,2007;Fields,2005;Kaushal,etal.,2001
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Preventing
harmfrom
infused
medications
StateConfirmsMedicalError
InHospitalDeathOfTeen
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Nursedidntbothertoreadthelabel
DennisQuaid
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IVMedicationAdministrationErrors
Fewprospectivestudiesofferdetailedanalysis
regardingtheincidenceandcausesofIV
medicationadministrationerrors
Limitedresearchfindingssuggest:
ErrorsassociatedwithIVinfusionpumpsoccur
frequentlyandarediverseinnature
Wrongrateerrorsarecommon,particularlywith
injectionofbolusdoses
Han,2005;Taxis,2003
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Whatweknow
Nursesspend26.9%oftheirtimeonthecritical
taskofmedicationadministration(Keohane,Bane,
Featherstone,etal.,2008)
Approximatelyofmedicaonadministraon
timerelatedtodrugdeliverytothepatient,and
theotherspentpreparingdrugsfor
administration(Hendrich,Chow,Skierczynski,&Lu,Z.,2008)
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HighAlertMedications
Developatargetedlist
Definestrategiesacrossthemedicationuse
system
Procurement
Prescribing
Transcription
Preparation
Labeling
Dispensing
Storage
Administration
Monitoring
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RankOrderofErrorReductionStrategies
Forcingfunctionsandconstraints

Automationandcomputerization

Standardizationandprotocols

Checklistsanddoublechecksystems

Rulesandpolicies

Education/information

Bemorecareful
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IndependentDoubleCheck
Twonursescheck
thedrug,dose,
patient,line
attachment,and
pumpsettings
before
administrationofa
targetedhighalert
medication
Smetzer &Cohen,2007
IndependentDoubleCheck
Twonurses
Medication(s)
Medicationadministrationrecord(MAR)or
electronicMAR(eMAR)
Bedsideconfirmationofpatientidentification
andIVpumpsettings
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17
Questions
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References
Barker,K.N.,Flynn,E.A.,&Pepper,G.A.,etal.(2002).Medicationerrorsobserved
in36healthcarefacilities.ArchivesofInternalMedicine,162:18971903.
Bates,D.W.,Cullen,D.J.,Laird,N.,Petersen,L.A.,Small,S.D.,Servi,D.,etal.
(1995).Incidenceofadversedrugeventsandpotentialadversedrugevents:
implicationsforprevention.JournaloftheAmericanMedicalAssociation,274, 29
34.
Cohen,M.R.(Ed.)(2007).Medicationerrors(2nded.).Washington,DC:American
PharmacistsAssociation.
Fields,M.,&Peterman,J.(2005).Intravenousmedicationsafetysystemaverts
highriskmedicationerrorsandprovidesactionabledata.NursingAdministration
Quarterly,29(1),7887.
Han,P.Y.,Coombes,I.D.,&Gree,B.(2005).Factorspredictiveoffluid
administrationerrorsinAustraliansurgicalcarewards.QualityandSafetyinHealth
Care,14, 179184.
Hendrich,Chow,Skierczynski,&Lu,Z.(2008). A36Hospitaltimeandmotionstudy:
howdomedicalsurgicalnursesspendtheirtime? ThePermanenteJournal,12 (3),
2534.
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References
Kaushal,R.,Bates,D.W.,Landrigan,C.,McKenna,K.J.,Clapp,M.D.,Federico,F.,et
al.(2001).Medicationerrorsandadversedrugeventsinpediatricinpatients.
JournaloftheAmericanMedicalAssociation,285(16),21142120.
Keohane,CA,Bane,AD,Featherstone,E,Hayes,J,Woolf,S,Hurley,A.,et.al.(2008).
QuantifyingNursingWorkflowinMedicationAdministration.JournalofNursing
Administration.38(1)pp 1926.
Kohn,L.T.,Corrigan,J.M.,&Donaldson,M.S.(Eds.)(1999).Toerrishuman:
buildingasaferhealthsystem. Washington,DC:NationalAcademyPress.
Leape,L.L.,Bates,D.W.,Cullen,D.J.,Cooper,J.,Demonaco,H.J.,Gallivam,T.,et
al.(1995).Systemanalysisofadversedrugevents.JournaloftheAmericanMedical
Association,274(1),3543.
Pepper,G.(1995).Errorsindrugadministrationbynurses.AmericanJournalof
HealthSystemPharmacists,52,390395.
Smetzer J,CohenM.(2007)Preventingadministrationerrors.In:CohenM,ed.
MedicationErrors.2nded.WashingtonDC:AmericanPharmacistsAssociation;
2007:235.
Taxis,K,&Barber,N.(2003).Causesofintravenousmedicationerrors:an
ethnographicstudy.QualityandSafetyinHealthCare,12(5),343347.
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