DRUG ERROR

1. DRUG ERROR WHAT CAUSES DRUG ERRORS Fadzai and Cecilia

2. What is drug error • Drug error can be identified as any aspect of commission or omission that militates against the achievement of the therapeutic objective e.g. benefit for the patient

3. Drug error • INCOMPLETE PATIENT INFORMATION (NOT KNOWING ABOUT THE PATIENT ALLERGIES AND OTHER MEDICINE • PREVIOUS DIAGNOSIS AND LAB RESULT • UNAVAILABLE DRUG INFORMATION (SUCH AS LACK OF UPTODATE WARNING BETWEEN DRUGS WITH SIMILAR NAMES • MISCOMMUNICATION OFDRUG ORDERS WHICH CAN INVOLVE POOR HANDWRITING,CONFUSING BETWEEN DRUG WITH SIMILAR NAM • LACK OF PROPER N LABELLING AS A DRUG IS PREPARED AND REPACKED INTO SMALLER UNITS • ENVIRONMENTAL FACTORS SUCH AS LIGHTING ,HEATNOISE AN D IMTERRUPTION PROFESSINOAL FROM THEIR MEDICAL TASK • LACK OF TRAINING FOR ADMINISTRATION OF DRUGS • POOR DRUG CALCULATION SKILLS(NURSES AND DOCTORS) • CHECKING DRUG CAN BECOME RITUALISES GIVING A FALSE SENSE OF SECURITY E,G GIVING THE TABLETS WITHOUT CHECKING THE LABEL

4. Drug error • Failure of correct dose and correct identity of patient • Unfamiliar environment • Attention slips for example error in units or decimals, point • Poor communication e.g. failure to take history of non prescription drug use • Wrong drug or wrong dose ,using the wrong route and failing to check observations

5. LEGAL ASPECT OF DRUG ERROR • When an error happens it should be reported immediately to the line manger • This is to offer support or reversing the effects of medication administration • Incidence report should be written • Management will offer staff (practitioners support mechanism to anger or help identify the problem

6. LEGAL ASPECT • Documentation should be followed by checking to see if patient had an reaction to the medication • The law require that the medication should be given to the right person, at the right time using the correct dose via the correct route • be aware of the patient care plan • The medication should be signed and dated by the authorised prescribe • Nurses should work within the professional standard set by the board (UK central council for nurses ,midwives and health visitors (UKCC)

7. LEGAL ASPECTS • It is important to recognise that information about medicine and their management keeps changing and that practising nurses have a responsibility to keep pace with new development • The nurse must be fully conversant with policies and procedures and adhere to them at all times

8. REFERENCES Nursing and midwifery Council (2004) The NMC Code of professional Conduct. Guidelines for administration of medicines Griffith ,R (2003) Administration of medicines part 1: The law and nursing. Nursing Standard. 18, 2,47-53.