Medication Error Reporting and Evaluation

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					                                       Medication Error                     POLICY 6.09.02
                                                                            Patient Care
                                        Reporting and                       Medication Error Reporting and
                                                                            Evaluation
                                         Evaluation                         Issued: July 1994
                                                                            Last Approved: July 2008


Office of Origin:       Patient Safety and Quality Services

I.      PURPOSE
        The purpose of this policy is to describe the Medication Error Reporting program of
        UCSF Medical Center and the role of key individuals participating in this program. The
        primary goal of this Medication Error Reporting Program is to ensure accurate and
        appropriate usage of medications. There are inherent risks associated with the therapeutic
        use of medications. However, with appropriate identification of an error and the
        documentation, assessment of medication errors and trend analysis, education, and
        improvement in systems, medication errors can be minimized to insure that the
        medication process is safe.
II.     REFERENCES
        Administrative Policy 3.06.03 Incident Reporting
        Administrative Policy 6.09.01 Adverse Drug Reaction (ADR) Reporting Program
        Administrative Policy 6.09.11 Medication Management: Ordering and Transcribing
III.    DEFINITIONS
        Medication Error: 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. A medication error can be a mistake in any step of the
        medication management process or system (e.g. selecting, prescribing, administering or
        monitoring), regardless of the causes and regardless of whether or not the error reaches
        the patient. (Note: This definition relates of medication errors is not meant to define
        medication error for legal or standard of care purposes.)
        Medication Administration Record: this term is used generically refer to all forms of
        record used to document the administration of medications.
IV.     POLICY
        A. Medications shall be properly prescribed, dispensed, and administered in accordance
           with the Medical Center, Department of Nursing, Department of Pharmacy polices
           and procedures, and patient “Rights” (Right patient, Right medication, Right dose,
           Right time, Right route/administration technique, and Right monitoring).
        B. All errors or events associated with the medication system or a step in the medication
           process shall be reported using an incident report, whether or not the error reached
           the patient.
        C. Physicians, or the appropriate prescriber, must be notified as soon as reasonable of
           medication errors that have reached the patient when:
            1. The errors are deemed to be clinically significant, and/or
            2. Involve medications that are not administered as ordered. Examples include
               wrong dose, wrong route, omitted dose, extra dose, medications ordered to be
               given STAT/NOW that are given late, and medications not given at the ordered
               time interval, e.g., ordered every 6 hours and given late.


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                                    Medication Error                  POLICY 6.09.02
                                                                      Patient Care
                                     Reporting and                    Medication Error Reporting and
                                                                      Evaluation
                                      Evaluation                      Issued: July 1994
                                                                      Last Approved: July 2008


        3. Physician/prescriber notification must be documented in the medical record using
           the Provider Contact Note (Ucare) or other appropriate note.
     D. For medications ordered as routine that are given late, communication with the
        physician/prescriber occurs through documentation on the medication administration
        record. The physician/prescriber should be notified as above in the event that late
        administration is deemed clinically significant.
     E. Medication errors will be reported using the online Incident Reporting System and
        managed according to the UCSF Medical Center Administrative Incident Reporting
        Policy 3.06.03. Quarterly trended reports will be produced by the System
        Administrator and distributed to the Category Managers and Supervisors. Semi-
        annual reports and analysis will be presented to the Medication Safety Sub-
        Committee by the Category manager and Pharmacy. Yearly reports and analysis will
        be presented to the Medical Center Clinical Performance Improvement Committee by
        the Category Manager. Incident Reports which reflect serious patient care
        management issues will be referred to the Patient Safety Committee and other
        appropriate quality committees for review and action.
V.   PROCEDURES
     A. Reporting
        The individual who makes or discovers the medication error shall complete and
        submit a report using the online incident report form. Visit the IR website at
        https://hsiis01.ucdmc.ucdavis.edu/ir/content/index.jsp. The subcategory to select
        under the Medication Related Events Category is Medication Errors/Delays. The
        Confidential Medication Error Incident Report Form (Form #862-064Z) is available
        for reporting if the online system is down, or there are issues with online access. See
        UCSF Medical Center Incident Report policy 3.06.03 for additional details.
     B. The following information shall be recorded using the online Medication Error
        Incident Report:
        1. Name of the Medication involved
            Use the drop-down list to locate name of medication involved in incident. If the
            medication name is not on the drop-down list, complete the text field.
        2. Type of error
            E.g. extra dose, improper dose/quantity, omission, wrong administration
            technique, wrong dosage form, wrong drug, wrong preparation, wrong patient,
            wrong route, wrong time, other (specify).
        3. Initial Node of the error
            Where in the medication process did the initial error occur? For example,
            prescribing, transcribing, dispensing, administering or monitoring.
        4. Examples of Errors
                   Prescribing: Illegible handwriting or unclear orders
                   Non-compliance with order-writing guidelines



                                       Page 2 of 4
                                Medication Error                POLICY 6.09.02
                                                                Patient Care
                                 Reporting and                  Medication Error Reporting and
                                                                Evaluation
                                  Evaluation                    Issued: July 1994
                                                                Last Approved: July 2008


              Wrong order form used
              Therapeutically incorrect orders
              Decimal point errors
              Documenting -Improper therapeutic screening of order at time of taking
               order off by nursing or pharmacy (dose, allergy check)
              Incorrect/incomplete transcription of order on MAR or Kardex
              Not transcribed onto MAR or Kardex
              Pharmacy transcription error
              Incorrect documentation of medication administered
              Dispensing -Medication not available due to delays in sending order,
               faxing order, processing order, delivery from pharmacy to unit, delivery
               to wrong place/unit, unknown delay
              Incorrectly dispensed/reconstituted/labeled by pharmacy
              Incorrectly diluted/reconstituted/labeled by nursing
              Incorrectly stocked in Pyxis by pharmacy
              Incorrectly accessed in Pyxis by nursing (includes Pyxis overrides)
              Administration -Misread orders/MAR/Kardex/label
              Forgot to give
              Incorrect pump setting/drip rate
              Gave to wrong patient
              Incorrect dose calculation
              Incorrect administration
              Equipment/device/tubing problem (e.g., tubing disconnects, tubing
               clamped)
              Monitoring -Improper monitoring of drug effect (e.g., narcotic
               administered to patient with low RR)
   5. Error Causes
       Possible Causes of Error (please select): While many errors have multiple
       causative factors associated with them, select the primary cause of the error.
       Some examples of causes include calculation error, sound-alike/look-alike,
       abbreviation, known allergy, decimal point, illegible handwriting, pump
       programming, and transcription.
C. Other Medication Related events
   1. Adverse Drug Reactions – use the ADR subcategory of Medication Related
      Events Category.


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                                          Medication Error                     POLICY 6.09.02
                                                                               Patient Care
                                           Reporting and                       Medication Error Reporting and
                                                                               Evaluation
                                            Evaluation                         Issued: July 1994
                                                                               Last Approved: July 2008


            2. Narcotic discrepancy - Should not be reported under medication related events.
               Choose Controlled Substances Accountability category of the IR system. See IR
               policy for further details and instructions.
VI.     RESPONSIBILITY
        Questions about the implementation of this policy should be directed to the Director of
        Performance Improvement or the identified Category Manager for Medication Errors.
VII.    HISTORY OF POLICY
        Approved April 2001 by Jane Hirsch, Associate Director and Mark R. Laret, CEO
        Revised and Reviewed April 2002 by Brigid Ide, Director of Performance Improvement
        Approved April 2003 by Mark R. Laret, CEO
        Revised December 2003 by Mary Passeri
        Reviewed January 2004 by Brigid Ide and Clifton Louie, Policy Steering Committee and
        Senior Executive Group
        Approved February 2004 by Executive Medical Board, Governance Advisory Council
        and Chancellor J. Michael Bishop
        Revised April 2008 by Maureen Buick RN, Jolene Carnagey RN, Adrienne Green MD,
        and Tina Yuen PharmD
        Reviewed June 2008 by Pharmacy & Therapeutics Committee
        Approved July 2008 by Executive Medical Board and Chancellor J. Michael Bishop




This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or
warranties are made for outside use. Not for outside production or publication without permission. Direct
         inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.




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