patient medication error case report

A Medication Error Report Form is a document used when reporting a medication error incident from health care settings like hospitals or clinics. This type of form helps to improve the way the medications are being administered and ensure the safety of the patient.

Full Answer

Why is it important to report all medication errors?

Why is it important to report all medication errors?

1. Make sure you understand the dosing instructions. Things that have a tapering dose like prednisone can be confusing.
2. Keep all your medicines together. Sort into "morning", "night" and "as needed". ...
3. For things taken every day, put a bit of painters tape on the lid. ...
4. Set them all out each morning as part of your routine. ...

How to document medication error?

Document your assessment of the patient immediately afterward. This is particularly relevant in the case of medication errors. Make note of who was notified about the mistake. For example, the patient themselves, the relatives, and the treating consultant. Lastly, document if you lodged an incident report. The discharge summary

What is considered a medication error?

The definition of a medication error includes mistakes that are made while making or administering the residents’ medications. A medication error is made when it is different from the doctor’s order or the manufacturer’s instructions, or when it falls below accepted professional standards for the medication.

What is the best way to prevent medication errors?

• Know the various risks and causes for medication errors. ...
• Find out what drug you're taking and what it is for. ...
• Find out how to take the drug and make sure you understand the directions. ...
• Check the container's label every time you take a drug. ...
• Keep drugs stored in their original containers. ...

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What are some examples of medication errors?

The three most common dispensing errors are: dispensing an incorrect medication, dosage strength or dosage form; miscalculating a dose; and failing to identify drug interactions or contraindications. Errors caused by drug administration can be made by the health care provider or by the patient themselves.

What should be included in a medication error report?

Any staff member who discovers a medication error, whether a physician, pharmacist or nurse, must immediately complete the Medication Error Report (Appendix I). The details include; patient name, hospital number, prescription details, details of errors and any incorrect medicine or dose administered to the patient.

What are the top 5 most common medical errors?

What Are the Top 5 Most Common Medical Errors?Misdiagnosis. Errors in diagnosis are one of the most common medical mistakes. ... Medication Errors. Medication errors are one of the most common mistakes that can occur during treatment. ... Infections. ... Falls. ... Being Sent Home Too Early.

What is the most common error in patient care?

Most Common Preventable Medical ErrorsMisdiagnosis. The wrong diagnosis can prove catastrophic to a patient in serious need of medical intervention. ... Medication Error. ... Faulty Medical Devices. ... Infection. ... Failure To Account For Surgical Equipment. ... Improper Medical Device Placement.

How do you document a medical error?

Disclosing medical errors the right wayBegin by stating there has been an error;Describe the course of events, using nontechnical language;State the nature of the mistake, consequences, and corrective action;Express personal regret and apologize;Elicit questions or concerns and address them; and.More items...

How are medication errors documented?

Medication errors are detected by voluntary reporting, direct observation, and chart review. Organizations need to establish systems for prevention of medication errors through analyzing the cause of errors to identify opportunities for quality improvement and system changes (Morimoto, Seger, Hsieh, & Bates, 2004).

Who is responsible for medication errors?

Who Can Be Liable for Prescription Drug Errors? In a nutshell, anyone and everyone along the chain of prescribing and administering a medication can be liable for prescription drug errors. This includes doctors, nurses, hospitals, the pharmacy departments in hospitals, pharmacists, and the pharmaceutical manufacturer.

How do you manage medication errors?

10 Strategies to Reduce Medication ErrorsMINIMIZE CLUTTER. ... VERIFY ORDERS. ... USE BARCODES. ... BE AWARE OF LOOK-ALIKE SOUND-ALIKE (LASA) DRUGS. ... HAVE A SECOND PAIR OF EYES CHECK PRESCRIPTIONS. ... DESIGN EFFECTIVE WARNING SYSTEMS. ... INVOLVE THE PATIENT. ... TRUST YOUR GUT.More items...•

What is the most common cause of medication errors in hospitals?

The most common causes of medication errors are: Poor communication between your doctors. Poor communication between you and your doctors. Drug names that sound alike and medications that look alike.

How do medication errors affect patients?

The knowledge that their death could have been prevented makes it harder still. Medication errors can result in severe patient injury or death, and they are preventable. Although most errors are minor, there is a huge spectrum—and some are fatal.

What errors are probably the most common medical errors?

Diagnosis Errors - Diagnosis errors are very common in the medical field, affecting up to 20 percent of medical cases in the United States. Diagnosis errors can include a missed diagnosis or a delayed diagnosis, both of which can have major implications for a patient.

What is medication error?

A medication error is any error occurring in the medication use process, including during prescribing, transcribing, dispensing, administration, adherence, and/or monitoring (2, 3). Medication error may not always result in injury and therefore will not always be an ADE. ADEs may be preventable or non-preventable.

What medications did the med REC report?

Admission medication reconciliation (MED REC) revealed that she was taking metoprolol, doxazosin, alprazolam, citalopram, and thiothixene (Navane) 10 mg twice daily.

What is medication reconciliation?

Conclusion. Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety.

What is an adverse drug event?

An adverse event is defined as an injury resulting from either medical intervention or omission, while an adverse drug event (ADE) is any injury due to a medication.

How much did the US spend on prescription drugs in 2010?

Spending in the United States for prescription drugs in 2010 was $259.1 billion and is expected to double over the next decade (3) (N). Total expenditures on the Medicare Part D program alone in 2012 were $66.9 billion and are projected to reach $165.1 billion by 2022 (3) (N). Conclusion.

What is a near miss in healthcare?

A serious event occurs, when a patient is harmed. An incident or ‘near miss’ is an event or error with the potential of harm that did not injure the patient (8).

What time did the attending physician call the hospital?

According to hospital records, the attending physician was called at approximately 10:00 p.m. and was advised that the patient had gone into cardiac arrest. The on-call emergency physician attempted to resuscitate, but was unable to obtain a heartbeat and the patient was pronounced dead.

What did the intensive care nurse fail to do?

The intensive care unit nurse failed to notify the physician that the patient’s heart rate was continuing to rise. She failed to follow the physician’s medication orders by administering an incorrect dosage of potassium at an incorrect rate. She then failed to properly document her actions.

Why are case reports written?

These reports are often written to document an unusual clinical presentation, treatment approach, side effect, or response to treatment. Most experts see case reports as the first line of evidence in health care, which can sometimes lead to future higher-level studies.

Why was Xarelto put on hold?

Investigation into the issue revealed that a prescription for Xarelto had been sent to his retail pharmacy to inquire about the cost of the medication with his insurance plan. The retail pharmacy then placed the medication on hold rather than discontinue the order entirely like the clinic staff had requested.

When was rythmol approved?

Rythmol (propafenone) is a class 1C antiarrhythmic drug that was FDA approved in 1989. In 2010, a case report was published documenting a medication error involving a handwritten prescription for Rythmol.

Did a school nurse administer Humalog U 100?

Officials learned that a school nurse inadvertently administered Humalog U-100 insulin instead of the influenza vaccine. Acute hypoglycemia was reported in all 5 patients who received the insulin with varying degrees of symptoms.

What happened to the patient who was rushed to the ER with anaphylaxis?

They rushed her to trauma, where a nurse administered epinephrine to help alleviate her symptoms. Immediately, the patient felt severe, crushing pain flow through her body that caused her to pass out.

How early did the nurse give the meds to the patient?

The night before his surgery, a nurse saw that the patient was expected to receive meds at 6 a.m., but he was also slated to leave for the operating room before 6 a.m. To keep him from skipping a dose, she administered the medication two hours early, at 4 a.m.

Why was the resident taking anticoagulant?

The resident was taking the drug, an anticoagulant, because they had a history of developing blood clots. During the nine-day window, the resident developed clots in their brain that eventually caused a large—and fatal—ischemic stroke.

What is QTC prolongation?

According to the Agency for Healthcare Research and Quality (AHRQ), which published the case study, the patient was found to have “severe QTc prolongation on his electrocardiogram, putting him at high risk for torsades de pointes, a sometimes fatal arrhythmia.” As a result, they had to postpone his surgery until his QTc returned to its regular level.

Who can report medication errors?

Reporting Medication Errors. Health care professionals and consumers have the opportunity to report the occurrence of medication errors to a variety of organizations. Examples include the Institute of Safe Medication Practices (ISMP) and the Food and Drug Administration (FDA).

Why do prescription errors occur?

Errors may occur because a prescription is never transmitted to a pharmacy, or a prescription is never filled by the patient. Physician sampling of medications can contribute to medication errors due to the lack of both adequate documentation and drug utilization review.

What is automated pharmacy dispensing system?

Automated pharmacy dispensing systems are more efficient at performing pharmacists’ tasks that require tedious, repetitive motions, high concentration and reliable record keeping, which can all lead to medication dispensing errors.

What is FDA MedWatch?

Although designed primarily for reporting adverse events from medication use, FDA's MedWatch is an appropriate venue to discover medication errors, such as prescribing misadventures and look-alike, sound-alike errors leading to adverse reactions .

How can electronic technology improve patient safety and reduce medication errors?

One way in which electronic technology can improve patient safety and reduce medication errors is through the use of standard machine-readable codes ("bar codes"). Medication bar coding is a tool that can help ensure that the right medication and the right dose are administered to the right patient.

Why do I get errors in prescribing?

Errors in prescribing can occur when an incorrect drug or dose is selected, or when a regimen is too complex. When prescriptions are transmitted orally, sound-alike names may cause error. Similarly, drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten.

Why is patient education important?

Patient education is an important aspect of any program to prevent medication misadventures. Organizations such as ISMP, and the FDA, as well as individual managed care organizations can help to evaluate the cause of medication errors.