Medication Error Intervention

Medication Error: Intervention

Immediate Interventions

■ Discontinue the medication. ■ Treat symptoms of ADR per protocol.

Focused Assessment

■ Assess for any ADR to the medication including changes in LOC, VS, N&V, allergic reaction, etc. ■ Ascertain whether Pt has any known allergy to medication given in error.

Ongoing Assessment and Intervention

■ Notify physician of medication error, along with any adverse reactions to medication.

Documentation

■ Complete appropriate documentation per hospital policy. ■ Document on MAR and progress notes if indicated. ■ Avoid using such phrases as “given in error.” State facts; document medication, dose, time, and route on MAR. ■ In progress notes, document physician notified. ■ If there was any ADR, include intervention and outcome. ■ Do not indicate within progress notes that an incident report was filled out (e.g., “see incident report”).

Preventing a Medication Error

■ Always observe the five medication rights. ■ Triple check all medications given. ■ Always read product packaging to note strength and route. ■ Always double check with pharmacist about dosage range. ■ When mixing insulin, have second nurse witness. ■ Always have colleague confirm dosage calculations and infusion pump programming. ■ Suspect missed decimal point and clarify any order if dose requires more than three dosing units. ■ Clarify any order that is unclear or contains abbreviations. ■ If taking verbal order, ask prescriber to spell out drug name and dosage to avoid sound-alike confusion (e.g., hearing Cerebyx for Celebrex, or 50 for 15). Read back the order to prescriber after you have written it in chart. ■ Label all syringes and discard syringe immediately after use. ■ Do not borrow medications from other Pts. ■ Do not begin new medications before order has been received in pharmacy, because this circumvents built-in checks that can detect potential error. ■ Document immediately after administering any medication. ■ Do not document medication until after it has been administered. ■ Never administer medication drawn up by another person. ■ Review each Pt’s medications for: ■ Medication use without an indication. ■ Contraindications. ■ Improper drug selection. ■ Overdose/subtherapeutic dose (consider age, renal/hepatic impairment). ■ Medication duplication. ■ Efficacy. ■ ADRs/toxicity. ■ Potential drug or food interactions. ■ Weight changes requiring dosage adjustments. ■ Appropriate duration of therapy. ■ Adherence with prescribed medication therapy.