RAHIMA M . SALENDAB NQMC,MGH, MADINA Meeqat Hospital,Madinah

1. RAHIMA M . SALENDAB
NQMC,MGH, MADINA

2. Medication Error: It 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. Such events may be related to professional practice, health care products and systems,
including: prescribing, order communication, product labeling, packaging and nomenclature,
compounding, dispensing, distribution, administration, education, monitoring and use.
DEFINITION:

7. PROCEDURES:

8. MEDICATION ERROR REPORT PROCESS
STAFF DISCOVERED
- Inform Head/Charge nurse
- Incident report (OVR) to be made
- Complete EMERF through alert system
-Assess & Monitor the patient
- Inform MRP/SOD
- Take action to solve the error
- Must be aware of:
*No disciplinary action to be taken
for the staff reported within 24 hours
Head/Charge Nurse
SOD (Supervisor on Duty)
- Must be aware of the incident
- Complete OVR
- Insure EMERF is done
- Inform Pharmacy
MRP (Most Responsible Physician)
- To take Appropriate action
- Fills in the designated area of EMERF the
appropriate action taken
- Inform Pharmacy immediately if the error
reach the patient and have necessitated
monitoring
Pharmacy
- Investigate the case
- Submit the written report to QPSD/Risk management
QPSD/Risk Management
- Do RCA
- Provide recommendation to resolve the problem
Medical Director
- Approve the learned action plan
- Disseminated learned action to all unit

14. Causes for errors:

15. TYPE OF MEDICATION ERROR
1. PRESCRIBING ERRORS .
2. OMISSION ERRORS.
3. WRONG TIME ERRORS.
4. UNAUTHORIZED DRUG ERRORS.
5. IMPROPER DRUG ERRORS .
6. WRONG DOSE FORM ERRORS.
7. WRONG DOSE PREPARATION ERRORS.
8. WRONG ADMINISTRATION TECHNIQUE ERRORS .
9. DETERIORATED DRUG ERRORS .
10.MONITORING ERRORS .
11.COMPLIANCE ERRORS .

16. 1. PRESCRIBING ERRORS
 Occurs when prescriber orders drug for specific patient
drug
dose
dosage form
route of administration
length of therapy
number of doses
administration
drug concentration
inadequate or incorrect instructions for use
illegible handwriting

17. 2. OMISSION ERRORS
Failure to administer an ordered dose
(not late dose).
Omitted dose is not an error when:
cannot take anything by mouth (NPO).
providers are waiting for drug level results.
patient refuses.

18. 3. WRONG TIME ERRORS
 Standardized administration times
 Acceptable interval surrounding scheduled time.
 Occasionally unavoidable:
patient is away care area for test.
medication is not available at time it is due.

19. 4. UNAUTHORIZED DRUG
ERRORS
 Administration of medication to patient without proper
authorization by prescriber.
 Medication for patient given to another patient.
 Nurse gives medication without prescriber order.
 Patients “share” prescriptions.

20. 5. IMPROPER DOSE ERRORS
 Dose that is greater or less than prescribed dose.
 Can occur when additional dose is administered
Delay in documenting dose
Absence of documentation
 Inaccurate measurement of oral liquid
Exclusions from this error type

21. 6. WRONG DOSAGE FORM
ERRORS
 Doses administered as different form than
ordered.

22. Example:

23. 8. WRONG ADMIN TECHNIQUE ERRORS
 Examples:
Subcutaneous injection that is given too deep
Intravenous (IV) drug is allowed to infuse via gravity
instead of using an IV pump.
Instilling eye drops in wrong eye.

24. 9. DETERIORATED DRUG
ERRORS
 Monitoring expiration dates is very important.
 Refrigerated drugs stored at room temperature may
decompose & lose efficacy.

25. 10. MONITORING ERRORS
 Inadequate drug therapy review.
 Examples:
Ordering serum drug levels but not reviewing
them.
Not ordering drug levels when required.
Prescribing antihypertensive agent & then failing
to check blood pressure.

26. 11. COMPLIANCE ERRORS
 Failure to adhere to prescribed drug
regimen.
Example:
Patient does not complete antibiotics
therapy-saves a few doses.

27. OTHER ERRORS
 Errors that cannot be placed into category.
Examples:
Medication dispensed without
adequate patient education.

30. UNAPPROVED ABBREVIATIONS LEADING
TO MEDICATION ERRORS:

31. Types of Verbal Order Errors

32. NURSING RESPONSIBILITIES

33. STANDARD PRECAUTION

34. LOOK ALIKE MEDICINE

36. SAMPLE OF ILLEGIBLE HAND WRITING

43. Folinic Acid Folic Acid
Amidaron Amlor
Zinnat Zantac
Concor Zocor
Tazocin Prazocin
Kafocid Keflex
Lasix Losec
Aldactone Aldomet
Ranitidine Loratidine
voltarin ventolin
SOUND ALIKE

45. HOW TO PREVENT MEDICATION
ERROR?????

46. Just because you cannot do it
TODAY
Does NOT mean you will not do
it SOMEDAY
‫اليوم‬ ‫ذلك‬ ‫تفعل‬ ‫لم‬ ‫ألنك‬ ‫فقط‬
,
‫ينب‬ ‫ال‬ ‫هذا‬
‫غي‬
‫ما‬ ً‫ا‬‫يوم‬ ‫ذلك‬ ‫تفعل‬ ‫لن‬ ‫انك‬
If you are not willing to learn, No one can
help you.
If you are determined to learn, No one can
stop you …!!
‫ان‬ ‫احد‬ ‫يستطيع‬ ‫لن‬ ‫تتعلم‬ ‫ان‬ ‫على‬ ً‫ا‬‫عازم‬ ‫تكن‬ ‫لم‬ ‫ان‬
‫يساعدك‬
‫سيوقفك‬ ‫من‬ ‫اليوجد‬ ‫فإنه‬ ‫تتعلم‬ ‫أن‬ ‫قررت‬ ‫إذا‬
NO ONE CAN MOTIVATE….
IF YOU ARE NOT WILLING TO
DO YOUR SELF…