Post-Conference Session Summaries

An Action Plan for Preventing Medication Errors

Instructional Session 7, presented Tuesday, April 24 and repeated Thursday, April 26

The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or consumer.”

Speakers Lisa Schulmeister, RN, MN, CS, OCN^®, and Patricia Baldwin, RN, MS, OCN^®, presented numerous examples of potential errors with chemotherapy, biotherapy, and supportive medications and offered many helpful ways to improve nursing practice to avoid mistakes. Chemotherapy presents a high risk for errors because of individual dosing, dose adjustments, and multiple calculations. The most common errors, in order of occurrence, are wrong dose, wrong time, wrong drug, wrong patient, and wrong route. The session provided many suggestions to combat such errors, a few of which are highlighted here.

Wrong Dose
Many dose errors are related to decimal points. Nurses can prevent decimal-related errors by avoiding a trailing zero (e.g., 2.0 mg), using a leading zero for doses less than 1 mg (e.g., 0.8 mg), using extra caution with multicopy order forms (because decimal points may not transfer to the last set), and posting usual dose ranges.

Other tips offered to prevent dose errors were to calculate body surface area (BSA) using the metric system, use online BSA calculators, double- and triple-check calculations, use two calculators with large buttons, compare orders with treatment plans, and use bar coding and other safety technology.

Wrong Drug
Drug names can lead to errors, such as those that look alike and/or sound alike (e.g., Doxil and doxorubicin, vincristine and vinblastine). In fact, half of the medication errors reported to the U.S. Food and Drug Administration MedWatch Program since 1992 were related to product labeling and packaging. Helpful suggestions: Post a cross-reference of trade and generic names, include on orders both names of new and unfamiliar drugs and of those with a high risk for error, place warning labels on storage bins, and store look-alike/sound-alike drugs in nonadjacent areas.

Wrong Patient
Nurses can avoid patient errors by using two identifiers other than a room or chair number, checking armbands, asking for full names and complete address, looking at driver's licenses, and assigning one nurse to care for patients with the same or similar names, so that the nurse is aware of the possibility for confusion.

Other Suggestions
The speakers also recommended that nurses

• Write indications on orders.
• Use personal digital assistants (known as PDAs) to send prescriptions to pharmacies, which can prevent issues that arise from poor handwriting.
• Write out confusing abbreviations.
• Use standard order sets whenever possible.
• Use commercially available strengths of medications rather than splitting tablets.
• Educate patients.

Medication errors can have serious consequences—injury to or death of patients, loss of a job or licensure, reprimand from an employer, legal action, and loss of confidence in professional abilities. The examples and suggestions presented can be applied easily to prevent costly and deadly mistakes.