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A recent Massachusetts study by researchers found that each month one out of every ten nursing home residents suffers a medication-related injury. Unfortunately, the more medications that a resident is taking increases the likelihood that an error will occur.  Recent Medicaid figures report that 68% of long-term care patients receive 9 or more prescription drugs, and 32% receive 20 or more prescription medications. A report entitled “Incidence and Preventability of Adverse Drug Events in the Nursing Home Setting”,  published in the American Journal of Medicine, found that medication errors in nursing home are common and often preventable. In 2005, the FDA ordered that Duragesic labels include a black box warning, which calls attention to the risks of using the patch and the signs of fentanyl overdose.  The new labeling includes information on respiratory and central nervous system problems and drug interactions that could occur when using fentanyl.
The information provided on this site concerning medication errors and medication overdoses is meant as a brief overview. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Some drugs must be stored in powdered form because they rapidly lose their power once they are mixed into a solution. The type of diluent you actually use will vary from patient to patient and should be specified in the drug order or dictated by the patient's chart along with hospital policy.
This is more than the amount of diluent you added because the drug itself takes up some of the volume in the solution. The expiration date of the mixed solution: 24 hours after the time that you originally mix the solution (if you leave the solution at room temperature). Notice that if you refrigerate the solution, you will need to look for the package insert to see when the solution will expire. Any other important details - for example, if there are different reconstitution directions for IV and IM used, we should indicate whether the medication is for IM or IV use. Some hospitals may also require that I put the date and time I prepared the drug on the label. Because there are two different choices of diluent, however, I must include the type of diluent on the label. Because Tazicef does not have more than one possible diluent, I do not need to write that the diluent was sterile water on the label, although it wouldn't hurt to include it. Because there are several different choices of concentration, however, I must include the concentration on the label. Because Pfizerpen does not have more than one possible diluent, I do not need to write that the diluent was sterile water on the label, although it wouldn't hurt to include it. Insulin is a substance produced by the pancreas that is used by the body to break down sugars in the blood. Giving a patient too little insulin does not adequately lower blood sugar so that they are still left with too much sugar in the blood; too much sugar the the blood can cause damage to blood vessels, leading to blindness, kidney failure, severe problems with limbs (especially the feet), stroke and heart disease. Giving a patient too much insulin can lower blood sugar too much and lead to dangerously low levels of sugar in the blood, which can cause seizures and coma, because the brain depends primarily on glucose (sugar) in the blood for fuel. Insulin is given by injection because it cannot be taken orally - the stomach will break it down so that is is no longer effective in breaking down blood sugar. Insulin is measured in International Units (units); most insulin is U-100, which means that 100 units of insulin are equal to 1 mL. This can be important, as a drug order may specify the origin of the prescribed insulin, because some patients respond more effectively to insulin from one source rather than another. The names lispro (brand name Humalog) and insulin aspart (brand name Novolog) both indicate rapid-action insulins. The names Regular and Semilente (the term used by the Humulin brand) both indicate fast-action insulins. The names NPH and Lente (the term used by the Humulin brand) both indicate intermediate action insulins. Long Action: The long-acting insulins begin to work in about 4 hours, peak in about 10 to 30 hours, and end in about 36 hours. Sometimes two different action speeds of insulin may be ordered to be given at the same time. To see examples of how to measure insulin doses in an insulin syringe, click the button below. These reports were analyzed to classify the events by node, related processes, possible causes, and contributing factors and to detect trends and noteworthy cases. Specific Federal and State laws and regulations apply and each case is unique and fact-intensive. While in a healthy adult it occurs naturally in the body, it can be manufactured from synthetic materials or harvested and refined from animal sources so that it can be given to patients who have a shortage of insulin in their bodies.
Someone who has diabetes has too much sugar in their blood; to maintain lower blood sugar levels that are in the normal range, diabetics are often given insulin. Even before a person's blood sugar level drops low enough to cause seizure or coma, low blood sugar levels can lead to mood swings, impaired mental function, blurred vision, nausea and vomiting, heart palipitations and shakiness. Common insulin U-100 syringes can hold 100 units; there are also Lo-dose syringes, which are syringes that can hold a total of 30 units or 50 units.
The name glargine (brand name Lantus) also indicates a relatively newly developed long-acting insulin, but it has a more even action which keeps insulin levels steady throughout the day, so it does not peak in the way that the other insulins do. Also, because there are different instructions for how to reconstitute this solution depending upon whether it is for IM or IV use, I must include that this mixture is for IM use only.
These rapid-acting insulins are taken at the beginning of a meal to counteract the rise in blood sugar due to eating, or they are used to lower blood sugar levels quickly when they are too high. Anti-infectives, opioids, and anticoagulants were the most common types of medications associated with wrong-patient events.
While multiple factors may have contributed to each event, the most common were two patients being prescribed the same medication, improper verification of patient identification, and similar room numbers.
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Important risk reduction strategies include ensuring proper storage of medications and patient-specific documents, utilizing healthcare technology fully, limiting verbal orders, and improving patient verification throughout the medication-use process.Introduction Patient misidentification has been a long-standing problem that has permeated all aspects of healthcare and led to errors ranging from wrong-site surgeries to discharging infants to the wrong families to ordering incompatible blood. All fields of the event reports, including harm score and care area, were self-reported, but the medication name fields were adjusted during analysis if information on the medication involved in the error had been available in the event description. Various trends were quantified using descriptive statistics.Aggregate AnalysisDuring the aforementioned reporting period, the Authority received 826 distinct medication error event reports from Pennsylvania healthcare facilities that were categorized as wrong-patient events.
However, based on the event descriptions, 13 reports (1.6% of total reports) did not actually involve wrong-patient errors and were excluded from the analysis.


The remaining 813 reports represent errors that occurred across the continuum of the medication-use process (from prescribing to administration and monitoring of medications), involved a wide range of medications, and occurred on various patient care units and departments.The errors reported occurred during all nodes of the medication-use process (see Figure). Almost 13% (n = 104) of reports listed anti-infective medications as being involved in the event. Of the reports involving a known single medication, almost 30% (n = 169) were associated with high-alert medications. The third most common care area noted in the reports was the emergency department (9.8%, n = 80). It is unclear, however, whether the locations noted in the event reports represent where the errors originated or where the errors were discovered.Despite the variety of medication errors involving the wrong patient, few resulted in patient harm. Medication procurement consists of a nurse obtaining the wrong medication from various medication storage areas (see Table 1).
For example, multiple reports described a nurse selecting the wrong patient from the automated dispensing cabinet (ADC) screen when retrieving medications. Monitoring is defined as patient assessment activities that occur before or after administration of medications.
Medication Storage Areas Involved in Events Occurring  during the Medication Procurement Process, as Reported to the  Pennsylvania Patient Safety Authority, July 2011 to December 2011Many factors, and often more than one factor per event, contributed to patients receiving other patients’ medications during actual medication administration. Most commonly, two patients were prescribed the same medication, and one received the medication dose intended for the other (14.3%, n = 41). The second most prevalent contributing factor was inadequate identification (ID) check (12.9%, n = 37), in which the event descriptions specifically mention failure to use two patient identifiers and to confirm identity with patient ID bracelets. In four reports (1.4%), the nurse used the patient’s or family’s acknowledgment of the name, which was incorrect, to verify identity.
The nurse either confused the patient with a roommate or administered the medication to the wrong patient due to similar room numbers. The nurse did not check the patient’s [ID] bracelet, and the patient received another patient’s morning medications.The patient was in the hall, and the nurse called the name of a patient. The patient responded “Yes.” The nurse looked at a picture and then asked the patient where her wristband was since it was not on the patient.
The patient responded, “I took it off a couple days ago.” The nurse looked at the patient’s picture and asked again, “Are you this patient?” The patient responded “Yes” and took the medications without questioning them. Later, the nurse realized that the two patients look very much alike.The nurse attempted to administer [a medication]. The nurse asked three adults in the room to verify the patient, since the patient was a pediatric patient and no ID bracelet was on.
All three verified and allowed the nurse to give the medication to the patient when it was the wrong patient.The wrong patient profile was viewed on the screen. The nurse pulled Vicodin® for pain for a patient in 123A but was on the patient in 123B medication profile. The scan matched and at this point, the nurse did not notice that he was on the wrong profile. The nurse approached 123A, scanned [the patient’s] bracelet, and administered the medication without checking the screen to see if the correct patient was scanned.Wrong-Patient Errors during TranscribingThe second most prevalent node in which errors originated was transcribing. Transcribing was defined as the process that involves the transferring of a paper medication order to a patient’s electronic or paper MAR.
Nurses, pharmacists, unit clerks, and others can perform this task; however, few of the reports identify the personnel involved.
Of the transcribing events, most errors were due to transferring orders into the wrong chart (81.4%, n = 253). Various contributing factors were identified, but none were associated with more than 4.1% (n = 4) of reports.
In one report, a physician gave a verbal order for a medication but did not use the patient’s full name.
The pharmacist was notified, who reported that the cardiologist called asking for a “stat” amiodarone for a patient but only gave the patient’s last name. It was later discovered that the patient was in the registration area but not yet admitted. The doctor had indicated that it was an urgent situation.The doctor came to see the patient, while the nurse was in the room, and discussed the medications he was going to order.
However, since the patient is in the same room with his wife, the doctor spoke to both of them.
When the doctor told the husband what medications he was going to write, he also told them to the nurse and went to the desk to write orders.
While looking over the copy of the orders, the nurse noticed they were written on an order sheet with the patient’s wife’s ID sticker on it. The nurse went to the wife’s chart and saw that the doctor had written the orders in the wrong chart. A filling error is made when a medication prescribed for one patient is dispensed from the pharmacy for a different patient.
When I called the pharmacy to inquire about it, the pharmacy said they had no recall of them sending the Levaquin for 465, but they said they did recall that it was sent for 456.
A pharmacist who was on the unit was approached by nursing about the delivery of the Fioricet, as it was not in the patient's drawer. The nurse happened to look in the medication drawer of another patient and discovered the Fioricet.Contributing Factors Associated with Wrong-Patient ErrorsBesides those mentioned above, several contributing factors that span the medication-use process were identified. Although the proportions were low, these characteristics were present in events that may have been prevented with system changes (see Table 2).  Table 2.
Contributing Factors and Characteristics of Wrong-Patient Errors,  as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011.In roughly 6% (n = 52) of the events, reporters mentioned that one patient was confused with another because both patients were to receive the same medication.
While most of the errors occurred during administration, four errors (7.7%) originated during prescribing.
In another example, a nurse confused intravenous (IV) medication bags for two of his patients who were on the same medication. Since I was all the way in the back hall, I removed both vancomycin [bags] from the fridge at the nursing station. ISMP has recommended that verbal orders be limited to use during emergencies and similar situations.12 The following example typifies a verbal order that was transcribed onto the wrong patient’s chart. Later, another patient was complaining of itching, and the nurse received a report that an order was obtained.


The low prevalence may be because many hospitals may already have mechanisms in place to prevent confusion between patients with similar names.
In fact, the assumption that similar names are the cause of most wrong-patient errors may result in other failure points being ignored. The example below mentions that two patients had the same first letter of their last names, but this was likely not the only reason for the incorrect transcription.An order for Imodium® 2 mg as needed was entered for the wrong patient on the same floor. The order was sent to the pharmacy two more times after the original was entered on the wrong patient. In one example, the confusion involved a discharged patient who had previously occupied the same bed. Two other examples described insulin pens of discharged patients being dispensed or used on current patients.
Even documents from discharged patients were mistaken for those of current patients.During the morning assessment, it was noticed that the previously infused antibiotic syringe on the IV pole with another patient’s name on the medication label was connected to current patient. The name and date of birth were on the label for a discharged patient, from the previous day, [who had occupied the] same room and bed.The patient in this room was ordered a heparin drip based on an ECG [electrocardiogram] strip on the chart that showed a rhythm of atrial fibrillation.
The ECG strip that was on the chart did not belong to this patient but was from the patient who had been in the room yesterday but had been discharged. The heparin drip was ordered this morning by the cardiology resident, and the error was found this afternoon during cardiology rounds by the cardiologist. The patient never received any heparin, and the order was discontinued as soon as it was discovered by the cardiologist.Finally, some reports described events in which patients or their family members caught wrong-patient errors. Below is an example that illustrates one such case.I was called to the patient’s room by the wife who noted, within 10 minutes of initiation of infusion, that the IV pump read vancomycin but the medication bag was labeled as acyclovir and with a different patient’s name. Dose immediately discontinued and no reaction noted.Risk Reduction StrategiesThe reports of wrong-patient events submitted to the Authority reveal the complex nature of wrong-patient medication errors (see Table 3). While often thought to occur only during administration, these types of errors were identified in all phases of the medication-use process.
Descriptions of How Wrong-Patient Medication Errors Occur,    by Node, as Reported to the Pennsylvania Patient Safety Authority,  July 2011 to December 2011     Improve Patient Verification for All Patient EncountersWhile the Joint Commission has an NPSG of improving the accuracy of patient identification, the proper use of two patient identifiers may still not be performed at all times.13,14 Such verification should be considered for all patient-associated tasks, including prescribing, reporting of test results, and communication of medication information between providers. Several reports illustrate examples whereby patients with similar room numbers or the same drug were prescribed, dispensed, or administered a dose intended for another patient. Overreliance on patient location and the name of the medication ordered may have contributed to one event reported to the Authority about a pharmacy technician dispensing an insulin pen with the label of a previous patient located in the same bed attached to it.
In fact, the Joint Commission’s NPSG requires healthcare practitioners to use at least two patient identifiers (not the patient’s room number or location) when providing care, treatment, and services.
If used, clearly label these bins and design them to facilitate medication delivery and retrieval. Moreover, some of the reports describe patients receiving the wrong medication because doses intended for other patients were placed in the former patients’ rooms.Similarly, store and return patient-specific documents in the patient’s chart.
For example, a misplaced monitoring sheet may result in an unnecessary treatment for another patient.
Standardizing the labeling practices for paper documents, monitoring sheets, and lab results can decrease the risk of wrong-patient errors.Lastly, institute procedures to remove medications and documents from active patient care areas when patients are discharged. Bar coding during medication administration can be a reliable double check if performed correctly. Some of the reports analyzed in this study stated that bar coding successfully detected the wrong-patient error; however, a number of reports indicated that improper use of scanning prevented the error from being caught. In these instances, nurses administered the medication first then scanned the patient’s armband second, or nurses failed to check for a confirmation from the scanning prior to administration. ISMP has received many reports similar to the latter example and has described this problem in its newsletters.19Hospitals often use ADCs as secure storage units for medications without fully using system capabilities to prevent errors. An ADC that allows nurses to override a majority of medications essentially eliminates a pharmacist’s double check of the prescriber’s order. Standardize policies that detail when verbal orders are appropriate, who may receive verbal orders, how to give and receive these orders, and the safety checks that should be used to prevent error. In an earlier example, the prescriber failed to provide appropriate identification and the pharmacist failed to confirm the patient’s identity by reading back patient identifiers in the chart.
They noticed IV bags with labels that had another patient’s name, and in one event described earlier, a family member even noticed the medication mismatch on the IV bag and the IV pump.Establish patient education programs to teach patients the importance of accurate patient identification during all points of contact and how staff should be verifying their identities. For example, if the facility uses bar-code identification, encourage the patient to speak up if his armband is not scanned prior to medication administration.
To accomplish this, some organizations have implemented programs in which patients and family members become active partners in ensuring patient safety. These programs include brief safety orientations for the patient upon admission, dedicated hotlines, and educational material listing questions that the patient should be asking the healthcare practitioners who care for them.ConclusionWrong-patient medication errors can occur at any phase of the medication-use process. While events reported to the Authority suggest that these errors occurred most often during administration and transcription, implementing safety strategies at all nodes can help to ensure that the correct patient receives the correct medication.AcknowledgmentsMichael J. Gaunt, PharmD, Pennsylvania Patient Safety Authority, contributed to manuscript preparation.NotesNational Patient Safety Agency. He thought the “lady in the door” was the “lady in the window”: a qualitative study of patient identification practices. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial [online]. The use of patient pictures and verification screens to reduce computerized provider order entry errors.
The physician taking care of Patient A asked the nurse to order vancomycin for that patient.
The nurse had the electronic charts for both Patient A and Patient B open and accidentally entered the medication on Patient B’s chart. The pharmacist verifying the order received a duplicate-medication alert from the computer system and realized that Patient B had already been started on vancomycin two days earlier.



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