Survey Adapted from Information Developed by HealthInsight, 2000. Adverse Drug Events R EDUCING MEDICATION ERRORS The Adverse Drug Events Survey will assist healthcare organizations evaluate the number and types of medication errors occurring in their facilities. This and other similar events are often underreported. This survey, administered anonymously to physicians, pharmacists and nurses, will provide detailed information regarding medication errors, including how they happen, when they occur, and their potential causes. The survey can be administered to one nursing unit or facility wide. Results can be analyzed in the aggregate by a nursing unit or by healthcare professionals. The survey examines four types of medication errors: Ordering errors, Order transcription and verification errors, Dispensing and delivery errors, and Administration errors For each area listed above, you are asked to describe the most recent occurrence you have observed. Please include errors that were prevented from affecting the patient (that is, those discovered before the medication was administered). Thank you for your help in this effort. Please answer all questions. Please use Section V. for any additional comments or concerns. Your input is greatly appreciated.
I. Medication Ordering Section This section relates to the most recent medication ordering error you have observed. Medication ordering errors might include, but are not limited to: ordering medications for which the patient has a known allergy, ordering the wrong dose, strength, or route of administration, etc. Remember, for this survey it does not matter if the medication was actually administered, just that there was an error in this phase. 1. How long ago was the most recent medication ordering error you have observed while working at this hospital? Wrong strength (e.g., 125mg/5cc instead of 250mg/5cc) Wrong route (e.g., IM instead of IV) Wrong total time of administration (e.g., 20 min IV infusion instead of 4hrs) Known interaction with current medication (e.g. erythromycin to patient on theophylline) Lack of knowledge about the medication (e.g., predictable adverse interaction with other current medications, excessive haloperidol in the elderly) Lack of knowledge about the patient (e.g., potassium chloride for patient in renal failure, dose not adjusted for renal function) Failure to follow established procedures (e.g., incomplete order, no route or frequency) Lack of monitoring or failure to use monitoring information (e.g., no checks of drug levels or adjustment of dose based on drug levels) Simple mistake (e.g., 1g instead of 1g/kg) 4. Was the error prevented (i.e., was the error discovered before the medication was administered)? PAGE 1
II. Order Transcription and Verification Section This section relates to the most recent medication or IV fluid order error you have observed related to transcribing, entering, and/or verifying an original order. Errors covered under this section might include, but are not limited to: missing orders, duplicate orders, and errors in recording verbal orders. Remember, it does not matter if the medication was actually administered, just that there was an error in this phase. 1. How long ago was the most recent order transcription and verification medication error you have observed while working at this hospital? Missed order Duplicate order Recording error Lack of knowledge about the medication (e.g., RN or clerk calls in or enters medication incorrectly) Lack of knowledge about the patient (e.g., known allergy) Difficulty reading physician handwriting Simple mistake (e.g., slip or memory lapse: q8hrs instead of q6hrs) 4. Was the error prevented (i.e., was the error discovered before the medication was administered)? PAGE 2
III. Medication Dispensing and Delivery Section This section relates to the most recent medication or IV fluid error you have observed related to medication dispensing and delivery. Errors covered under this section might include, but are not limited to: errors in dispensing medications (e.g., wrong drug or dose), significant delays in delivery to patient care unit (e.g. 6 to 12 hour delay in delivering antibiotics for patient with a serious infection), or medication administration record (MAR) errors. Remember, it does not matter if the medication was actually administered, just that there was an error in this phase. 1. How long ago was the most recent medication dispensing and delivery medication error you have observed while working at this hospital? Labeling unclear Delayed delivery Failure to follow standard procedures (e.g., new form or strength or preparation provided) Difficulty reading physician handwriting Poor communication/interaction with other services (e.g., delayed filling due to waiting for a written order despite verbal order given) Medication stocking and delivery problems (e.g., resulting in significant late delivery to patient care unit) Faulty medication identity checking (e.g., similar sounding drugs) Simple mistake (e.g., faulty dose checking or preparation error) 4. Was the error prevented (i.e., was the error discovered before the medication was administered)? PAGE 3
IV. Medication Administration Section This section relates to the most recent medication or IV fluid error you have observed related to medication administration. Errors covered under this section might include, but are not limited to those related to: nurse dispensing of floor stock, nurse administration of medications dispensed by the pharmacy, and nurse documentation of medications administered. Remember, it does not matter if the medication was actually administered, just that there was an error in this phase. 1. How long ago was the most recent medication administration error you have observed while working at this hospital? Documentation error (e.g., no charting or wrong time/day charted) Missed dose/duplicated dose/dose given at the wrong time Lack of knowledge about the medication (e.g., dilantin given in the IV fluids instead of normal saline) Lack of knowledge about the patient (e.g., antihypertensive medication given to patient with low blood pressure) Infusion pump and parenteral delivery problems Failure to follow established procedures (e.g., IV infusion of chemotherapy too fast) Faulty medication identity checking or faulty dose checking (e.g., confused drugs with similar names or packaging) Faulty patient identity checking 4. Was the error prevented (i.e., was the error discovered before the medication was administered)? PAGE 4
V. Other Section 1. Please check your job position. Nurse Pharmacist Physician 2. Fill in the average hours you work per week. hours/week (non-physicians only) 3. What patient care unit/department do you work in? 4. Is there anything else you would like us to know about the issues raised in this survey? If so, please use this space. Also, any comments you would like to make about improvements that could be made in the medication ordering, transcription, dispensing, and/or administration process would be appreciated. MO-03-03-PS October 2003 This material was adapted from information developed by HealthInsight and prepared by MissouriPRO under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy.