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Medication Error Reporting and Evaluation

Office of Origin: I. PURPOSE Patient Safety and Quality Services

POLICY 6.09.02

Patient Care Medication Error Reporting and Evaluation Issued: July 1994 Last Approved: August 2011

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 Nursing Administrative Policy Research on Patient Care Units 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

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Medication Error Reporting and Evaluation

POLICY 6.09.02

Patient Care Medication Error Reporting and Evaluation Issued: July 1994 Last Approved: August 2011

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. 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. Semiannual reports and analysis will be presented to the Medication Safety SubCommittee 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.

F. Medication errors that involve investigational drugs require the primary investigator be notified.

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.

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Medication Error Reporting and Evaluation

4. Examples of Errors

POLICY 6.09.02

Patient Care Medication Error Reporting and Evaluation Issued: July 1994 Last Approved: August 2011

Prescribing: Illegible handwriting or unclear orders Non-compliance with order-writing guidelines 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,

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Medication Error Reporting and Evaluation

POLICY 6.09.02

Patient Care Medication Error Reporting and Evaluation Issued: July 1994 Last Approved: August 2011

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. 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 Reviewed August 2011 by Bret Brodowy, Interim Director of Pharmacy and Maureen Doherty, Director, Nursing Standards

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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