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Drug Errors

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by

Amelia Bell

on 6 February 2014

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Transcript of Drug Errors

Amelia Bell
Drug Errors
National Patient Safety Agency
Every day approx 2.5 Million medicines are prescribed in the community and in hospitals across the UK
6.5% of patients admitted to hospital and 9% of those staying in hospital experience a medication related error
.
Wrong Dose
Wrong Medication
Omitted Medication
Most Common Errors
A patient on warfarin had a GI bleed after being discharged without follow up appointments

Patient died after being given 30mg IV dose of diamorphine instead of a 5mg dose

A child needed their stomach pumping after having 12 times the intended dose of clonazepam due to a prescribing and administration error
Some Examples
www.nmc-uk.org
What is the role of the NMC in drug errors?
The NMC review cases put forward by the trust and the registrant may have to face a fitness for practice panel
The NMC have a number of sanctions they can order when reviewing a case:

1) No further Action
2) Caution Order (1 to 5 years)
3) Conditions of Practice Order
4) Suspension Order
5) Striking-Off Order
NMC OUTCOMES
Let's look at a scenario!

What would you do?
What Steps can we take to prevent drug
errors occurring?
The Five Rights

1) Right Patient
2) Right Drug
3) Right Dose
4) Right Route
5) Right Time

Remember to check it is signed and legible
The Doctor
The Nurse in charge
The pharmacist

Follow the hospital policy and always report things promptly to ensure any harm to the patient is avoided
Who Should you inform?
What does 'The Code' (2011) state?

You must act without delay if you believe that you, a colleague or anyone else may be putting someone at risk.

You must act immediately to put matters right if someone in your care has suffered harm for any reason.


REMEMBER 'SAFELINE' IS AN OPTION.
What if I am worried about a colleague making errors?
Remember the 5 rights

Always report any errors or concerns

Engage with the drugs round
so ......
Any Questions????
Thank you for listening
The NMC standards for Medication Administration (2008)
STRIKING OFF ORDER
NMC DECISION
Do you agree?
NMC Decision
STRIKING OFF ORDER
NMC DECISION
Caution order for 3 years
Full transcript