70 Ways to Mess Up Your Medications
CHOOSING A MEDICATION AND ITS DOSE AND SCHEDULE
1. The wrong diagnosis is made.
2. The wrong pharmaceutical is chosen to treat a condition.
3. The wrong dose is calculated for a pharmaceutical.
4. The wrong schedule is chosen for a pharmaceutical.
ORDERING A MEDICATION
5. Physician may make incorrect TDS order/entry.
6. A verbal order is misunderstood.
7. A verbal order is mistranscribed onto the NCR order form.
8. A verbal order is not written.
9. A written order is written incorrectly.
10. A written order is illegible.
11. A written order is misread.
12. A written order is mistranscribed into the Kardex and medication administration record in a manual system.
13. A written order is mistranscribed into TDS.
14. A order is mistranscribed into HP CareView.
15. Nurse does not check summary of order transcription when entered by the unit secretary.
16. Order delivery to pharmacy is delayed.
17. Order is not faxed to pharmacy.
18. There are too many ways to order a medication.
19. MAPS should be incorporated into the medication ordering process.
20. TDS miscellaneous scheduling function omission errors need to be reduced.
DISPENSING A MEDICATION
21. Pharmacist makes error in entering order into TPN system.
22. Pharmacist makes error in checking TPN order entry.
23. CAPS makes error in preparing TPN.
24. Pharmacist makes error in checking oral/intravenous medication order.
25. Pharmacist makes error in entering order into oral/intravenous system.
26. Pharmacist makes error in filling the prescription.
27. Pharmacist makes error in checking the filled prescription against the order and labels.
28. Pharmaceutical delivery to nursing unit is delayed.
29. Pharmacist makes error in checking order for a pharmaceutical available Pyxis.
30. Pharmacist makes error in calculation when checking order for a pharmaceutical available in Pyxis.
31. The TPN and oral/intravenous medication computer systems are separate.
32. TPN-medication interactions may be difficult to identify.
ADMINISTERING A MEDICATION
33. Nurse leaves a medication off the doses due list.
34. Nurse determines wrong time for administration.
35. Medication is overlooked on the nursing unit.
36. Nurse chooses wrong medication from Pyxis.
37. Medication is stored improperly on the nursing unit.
38. Medication may be missed on the nursing unit since there are so many locations to check.
39. Nurse or physician does not check if medication is the right drug and right route.
40. Nurse or physician makes mistake in checking if medication is the right drug and right route.
41. Nurse or physician may choose wrong route of administration.
42. Nurse or physician does not follow drug-specific guideline.
43. Drug-specific guideline is not available.
44. Nurse or physician misidentifies patient to be given a pharmaceutical.
45. Patient is not available for pharmaceutical administration.
46. Nurse or physician misidentifies patient to be given a pharmaceutical.
47. No check for correct dilution of medication.
48. Administration of drug may be too fast or too slow.
49. Administration of pharmaceutical is not documented in the medication administration record.
50. Pyxis has very little oversight by Pharmacy.
MONITORING FOR MEDICATION
51. Medication error is missed.
MONITORING FOR ADVERSE DRUG REACTIONS
52. Adverse drug reaction is missed.
53. Adverse drug reaction is attributed to another etiology.
54. Reaction may be viewed as expected rather than an adverse drug reaction.
55. Adverse drug reaction is not documented on patient record.
56. How do we provide feedback to those involved in medication errors and adverse drug reactions?
57. How are patients identified who have had an adverse drug reaction such as an allergic reaction to a medication?
OPERATING & RECOVERY ROOMS
58. In the operating room, anesthesia dispensing of drugs is not checked by pharmacy or ursing.
59. In the operating room, the anesthetist may give the wrong drug.
60. In the operating room, the anesthetist may give the wrong drug.
61. In the operating room, the surgeon may choose the wrong route.
62. In the operating room, the anesthesia preparation of drugs is not checked by pharmacy or nursing.
63. In the operating room, the anesthetist may make the wrong dilution.
64. In the operating room, the nursing preparation of a medication is not checked.
65. In the recovery room, the pharmacist may make an error in preparing the medication.
66. Delivery of the medication from the pharmacist to the recovery room may be delayed.
67. In the recovery room, the nurse or physician may forget to check the safety and appropriateness of a drug.
68. In the recovery room, the nurse or physician may improperly check the safety and appropriateness of a drug.
69. In the recovery room, the nurse or physician may miss a safety or appropriateness problem of the drug.
70. In the recovery room, there is no double check on the nurse/physician check of a drug once delivered from the Pharmacy.
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