Medication Error
27/12/10
SP Notes
FANZCA Part II Notes
ANZCA Professional Document PS51 – 2009
Medication error = a medication given in mistake that may or may not have an adverse clinical outcome.
- drug error incidence = 1/135 anaesthesia
- can cause significant harm to patients
- need to recognise and adopt techniques to minimise such events
PREDISPOSING FACTORS
ICU factors
- complex environment: high stress, high turnover, high nursing turnover
- emergency admissions
- multiple care providers
- storage area
- mis-communication when patients transferred from wards/inter-hospital
Medication factors
- packaging: often many drugs have similar packaging (narcotics)
- often infusions based
- patient on multiple infusions
Patient factors
- severity of illness
- time critical drug administration
- extremes of age
- prolonged hospitalisation
- sedation
MANAGEMENT
General
- aim = give correct drug, to correct patient by correct route and record information accurately
- we should know physiology, pharmacology and how to manage complications
- take thorough drug history
- drugs administered by non-medical personnel should have medical supervision and a written order
- write legibly
- good communication
- minimise distraction when drawing up
- adequate light
- bar code technology
- medication reconciliation
- avoid fatigue and cumulative working hours
- minimise interruptions and distractions
- adequate staffing
- Pharmacist participation
- quality assurance as a part of education program
- decrease nurse to patient ratio
- AIMS ICU (Australasian Incident Monitoring Study in ICU)
Purchasing
- purchasing and inventory should minimise drug error
- avoidance of look-a-like packaging
- changes to packaging must be widely communicated
- stocking of different concentrations should be avoided
- avoid need for dilution (pre-diluted)
Storage (workspace)
- tidy
- organised
- standardised
- emergency drug drawer
- look-alike ampoules -> store apart
- store in original packaging prior to drawing up
- appropriate trays
Labels
- labels should have agreed and clear writing
- pre-printed labels should be colour coded by drug class
- if labels not available -> permanent marker pen
Drawing up and checking drugs prior to Administration
- read label (check name and dose)
- regular checking for expired drugs
- label syringes appropriately
- draw up one drug @ a time and label
- if interrupted when drawing up a drug -> discard
- before administering check drug and dose with a second person or an automated device
- any one ampoule should be administered to only one patient
Storage
- time interval from drawing up and administering should be short
- store logically and orderly
- drugs with different routes should not be stored together
- emergency drugs should only be drawn up where there is time critical response -> otherwise can be given inadvertently.
Maintenance of Accurate Records
- keep accurate records
- keep ampoules so drugs can be reconciled if problem develops
- discard ampoules once finished with
Infusion Drugs
- infusion pumps and syringe drivers should be standardised
- label patient end of the infusion
- caution of one way valves to avoid siphoning of infused drug
Jeremy Fernando (2010)