I recently read that the most frequent medication error was a
missed dose. A few years ago, we had no way to tell if we had a missed
dose or not, so we went to a unit dose system of medication
administration. We still have an occasional missed dose, but for the
most part this system corrected the problems we we having.
On a normal day, our nurses give over 350 medications on the
morning medication pass. We have 75 residents in our facility. I get a
missed medication error report about 1 or 2 times a month. This is a
very small % of the medications that need to be passed in a month's
time.
We also do Primary assignments for the staff in our facility. This
too has helped to reduce medication errors. Each unit is staffed with
day, evening and night shift primay nursing staff and CNA staff. I
still have RN/LPN staff that float from unit to unit on the full-time
nurses days off. Everyone is fairly comfortable with what the residents
receive on a routine basis, therefore, lessening the error rate.
Since our medications are exchanged on a weekly basis, new
medications get sent at the same time as the routine medications.
We have set-up a system with our local pharmacies, that we fax them
changes in medication and treatment orders as they arrive. They will
deliver the new medications any day of the week and fill the cassettes
with the number of doses needed until the next exchange day.
Our most frequent medications errors now, are pharmacy related.
Most of those are labeling errors (no expiration date, which we do not
accept; cassette missed on med exchange; Rarely the wrong medication in
a cassette, or the wrong dose of the medication in a cassette.)
We also treat medications errors as learning experiences. As I
manage the RN/LPN staff, in addition to RAI Coordination, I discuss
individual errors with the nurse involved as soon as possible so they
are aware of the error made and can tell me how they will correct the
situation so that it does not happen again. I very seldom have to go to
disciplinary action due to medication errors.
My tracking and trending includes not only the error made, but the
medication involved, and the staff member/members responsible for the
error. Only 1 time this year have I identified a trend of a staff
member in a month's time frame.
We have made it a policy that all physician orders must be checked
for completion and co-signed by a second charge nurse. Both nurses are
held accountable if there is an error in transcription that resulted in
an error in treatment of any kind. This has helped my transcription
errors greatly. They are help each other to get things right.
Just an FYI, I see very little difference in medication error rates
between RN and LPN staff nurses, new or seasoned nurses. The difference
I have identified is the dedication to the profession and accountability
for job performance.
I hope this helped.
Julia
Julia A. Onken, R.N. LTC Nurse Manager
Goshen Care Center
2009 Laramie Street
Torrington, WY 82240
Phone (307) 532-4038 ex. 3044
Fax (307) 532-3800
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]
Sent: Tuesday, November 04, 2003 6:14 PM
To: [EMAIL PROTECTED]
Subject: Medication Errors
Am I getting too old,is it time to retire?I feel I work at a facility
that gives very good care and we have a great reputation in
community.,our beds are always filled with a waiting list.Having said
all this I am seeing an increase in medication errors on our snf unit as
I am the PPS person.As a new grad I remember making only one medication
error that blew me away.I was so upset.I am seeing new nurses not too
concerned with their mistakes and our DON doesn't appear too worried.In
the Northeast where I work we are seeing a growing shortage of nurses
esp RNs so we have hired new LPN grads.They are very nice girls but what
are they being taught.I am not trying to get into a LPN vs.RN issue.Our
choice is to either contract with nsg agencies or hire new nurses and
LPNs are who have applied.I know I recently read somewhere about the
growing med errors in acute care also[most acute care nurses are RNs]I
never thought I would hear myself say that maybe med techs are the
answer.Are we asking too much of the nurse giving meds so that they
can't concentrate.I know when I use to do a med pass,I had to pay
attention.I didn't want to be interupted during the pass.We have signs
on our med carts to not disturb.I am very concerned with this trend I am
seeing.Does anyone else have this concern in their facility?
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The Case Mix Discussion Group is a free service of the
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/----------------------------------------------------------
The Case Mix Discussion Group is a free service of the
American Association of Nurse Assessment Coordinators
"Committed to the Assessment Professional"
Be sure to visit the AANAC website. Accurate answers to your
questions posted to NAC News and FAQs.
For more info visit us at http://www.aanac.org
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