There have been deaths reported at other hospitals when
Low molecular weight heparin (e.g. Lovenox, Fragmin) are used with heparin resulting in
hemorrhaging. In one case, a nurse borrowed a drug from another patient before the order
could be verified and the interaction caught by the pharmacist.
Nurses working for ISMP who have seen so many med
errors reported would now do things differently if they returned to the bedside.
Note: Our comments in bold.
- Enlist the help of patients (e.g. to ensure staff checks
their ID bracelet) to safeguard against
errors. Do you check the patient’s ID before giving a med?
- Communicate important information (allergies, height, weight,
Dx, etc.) to the pharmacy. Are you
forgetting to enter the allergy information into the Medical Record?
- Make pharmacists a valuable member of the team.
- Take the medication administration record (MAR) to the
bedside. Do you always check the
medication profile before you administer a drug to ensure you get the "right drug to the
right patient"?
- Minimize the need for error-prone calculations.
- Do not sacrifice safety for timeliness. Wait for order verification.
Example: Avoid taking meds out of
PYXIS that are on override unless in an emergency.
- Ask for independent double check of high-alert drugs
before administration. These include insulin, heparin, PCA, chemotherapy and
neonate/pediatric meds.
- Take time to report errors. Don’t worry about getting
in trouble – if you don’t report, we
can’t learn from our mistakes, which many times are due to systems,
rather than people.
- Review the literature for reports of error that have occurred
in other organizations.
|
