Medication Errors

This position statement was archived on 11/7/2012 because it is now a standard of practice. Resources for preventing medication errors are available at the Agency for Healthcare Research and Quality (AHRQ).

IT IS THE POSITION OF AMSN THAT:

  • The medical-surgical nurse should collaborate with other disciplines to develop, implement, and evaluate institutional and unit-based medication administration policies and procedures regarding medication administration, medication reconciliation, prevention of medication errors, and reporting of adverse drug errors (ADEs).
  • The medical-surgical nurse can reduce the number of deaths attributed to medication errors and ADEs significantly by implementing the 10 rights of medication administration with every treatment:
    • Right medication
    • Right dose
    • Right time
    • Right route
    • Right client
    • Right patient education
    • Right documentation
    • Right to refuse medication
    • Right assessment
    • Right evaluation
  • The medical-surgical nurse resolves issues identified during the medication reconciliation process.
  • The medical-surgical nurse supports an environment of non-punitive reporting of medication errors and ADEs.
  • The medical-surgical should report system failures that impact the safe administration of medications.
  • A root cause analysis should be performed on all medication errors or ADEs. The root cause analysis findings should be utilized to bring about improvements in the medication administration process.
  • Health care administrators should promote a non-punitive environment to monitor and report medication errors and ADEs, provide an environment that promotes patient safety through conducting a root cause analysis of medication errors and ADEs, and implement unit dose, computerized physician order entry, and bar-coded medication administration programs.
  • Health care administrators must report medication errors and ADEs to the appropriate regulatory agency.
  • Technological tools that enhance communication and minimize opportunities for medication errors should be implemented in health care environments.

OVERVIEW:

Sakowski and Dozier (2008) report that medication errors resulting in patient harm are the leading cause of medication error-related deaths. Medication errors may not be reported due to the perception that the error did not cause harm or the fear of punitive action, the loss of professional reputation, or litigation.

RATIONALE:

Errors can occur in any stage of the medication administration process. The majority of errors happen during processing of the physician’s order or during the actual administration of the medication. Because physician orders pass through many reviews, most of the errors are caught before the patient actually receives the medication. However, the medical-surgical nurse is responsible for the final review before the medication is administered.

DEFINITIONS:

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.

Adverse drug error (ADE) is an incident in which the use of a medication at any dose, a medical device, or a special nutritional product may result in an adverse outcome in a patient.

REFERENCES:

Armitage, G. (2008). Double checking medicines: Defense against error or contributory factor? Journal of Evaluation in Clinical Practice, 14(4), 513-519.

The Joint Commission. (n.d.). Definition of adverse medication errors. Retrieved from http://www.thejointcommission.org/SentinelEvents/se_glossary.htm

The Joint Commision. (n.d.). Definition of medication error. Retrieved November 11, 2008, from http://npsf.disted.mcw.edu/InfoCenter/Glossary/m.asp

Pippins, J., Gandhi, T., Hamann, C., Ndumele, C., Labonville, S., Diedrichsen, E., et al. (2008). Classifying and predicting errors of inpatient medication reconciliation. Journal of General Internal Medicine, 23(9), 1414-1422.

The Joint Commission (n.d.). National patient safety goals. Retrieved September 19, 2009 from http://www.jointcommission.org

Sakowski, J., Newman, J., & Dozier, K. (2008). Severity of medication administration errors detected by a bar-code medication administration system. American Journal of Health-System Pharmacy, 65(17), 1661-1666.