Module 12 Medication Errors The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as follows any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care pr ID: 710780
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Slide1
Medication Pass
No Interruptions
Module 12Slide2
Medication Errors
The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as follows: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumerSlide3
Causes of Medication Error
Multiple factors can contribute to medication errorsincluding nurse’s workload
experience leveltranscription errors, and system deficienciesDistractions and interruptionsSlide4
Interrupted Workflow
In a French study, Tissot and colleagues reported that interrupted workflow during medication administration was a contributing factor to the 6.6% error rate in medication administration. Slide5
Interruptions
a break in continuity of complete focus on the task of preparing medicationverbal or nonverbal cue from another individual prompting the nurse to give a verbal or nonverbal response
losing focus on medication preparation and initiating conversation with another personSlide6
Strategies to Reduce Errors
Computer-based order entry Patient and medication barcode scanning
The “Sterile Cockpit Rule”No Interruption Zone (NIZ)Slide7
Sterile Cockpit Rule
The Federal Aviation Administration in 1981 enacted policies that prohibit nonessential tasks and communications by aircraft personnel during flight operationsDistractions and interruptions resulting in omissions or inappropriate actions during flight operations
This adherence to the sterile cockpit rule minimizes distractions during critical periods of flight operations and improves airline safety.Slide8
No Interruption Zone
The NIZ is fashioned after the aviation industry’s “sterile cockpit rule.”Change in nurses’ ability to pass medications more efficiently and think more clearly.
No interruptions during med passDo not allow distractionsAvoid personal conversations Avoid phone calls No multitaskingSlide9
Prevent Phone Distractions
Communicate prior to passing medications that you will unable to answer the phone and to take a messagePlace your phone on vibrate
Leave your phone with another nurseDo not multi-taskDo not answer the phone while preparing or administering medicationsSlide10
Patient Safety
Nurses are primarily responsible for medication safety National initiatives are calling for an increase in medication safety
During medication preparation, a No Interruption Zone could decrease interruptions and enhance safety