Medication Errors: Significant or Non-significant

Susan M Cleveland BSN, RN, WCC, CDP

From a regulatory viewpoint and the State Operations Manual (SOM) there are clear definitions of what is and is not a significant medication error.
“Medication error” means the observed or identified preparation or administration of medications or biologicals which is not in accordance with:
  1. The prescriber’s order;
  2. Manufacturer’s specifications (not recommendations) regarding the preparation and administration of the medication or biological; or
  3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standard established by national organizations, boards, and councils.
Significant medication error” means one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration.
For example, constipation that is unrelieved because an ordered laxative is omitted for one day, resulting in a medication error, may cause a resident slight discomfort or perhaps no discomfort at all. However, if this omission leads to constipation that persists for greater than three days, the medication error may be deemed significant since constipation that causes an obstruction or fecal impaction can directly jeopardize the resident’s health and safety.
There is room for interpretation and the SOM assists in the determination of significance by outlining professional judgement in relativity to the error.
  • Resident condition
  • Drug category
  • Frequency of error
Guidelines provided to assist in the analysis of the impact or outcome on the resident are based on objective measurable data, except we must not forget the ‘slight’ discomfort the resident may experience as stated in the definition.
Medication errors are cited at F760 in one of the following instances:
  1. Surveyor identifies a significant medication error during medication preparation and/or administration or
  2. Surveyor identifies a significant medication error during a resident record review.
Several types of errors may occur and often can be avoided with preparation and diligence. Preparation is the key to a successful med pass. Assure you have everything you need before starting the medication pass; set up your MAR, identify who is receiving medication and that the medication is available.
  • Timing errors - before meals, after meals and with food, when administrating out of the proper timeframe are considered as medication errors.
  • Omitting medication is never acceptable.
  • Wrong dosage form or wrong medication- constant updates and comparisons to the order and MAR, contact the pharmacy to obtain what has been ordered, complete three checks during a medication pass, this will help reduce, if not eliminate these types of error.
  • Failure to “shake well” – the desired therapeutic effect may not be obtained if the suspension is not thoroughly mixed.
  • Crushing medications- tablets, caplets, capsules, sublingual’s – this direction sometimes causes confusion. A ‘blanket’ order from the physician states that medication may be crushed is partially true. Certain manufacturer specified medications instructions state “do not crush”. In this instance, the physician or a pharmacist must explain, in the clinical record, why crushing the medication will not adversely affect the resident. Remember it is for the ease of the resident.
  • Providing/offering adequate fluids – some medications require a recommended amount of fluids to accompany the medication administration. Insufficient fluid may interfere with the medications therapeutic effect and is considered a medication error. When residents refuse to take fluids with medications you cannot be held at fault, but you have to offer them.
  • Administering eye drops - the dropper should never come in contact with the eye and the drop itself should not fall on the cornea, but into the lower conjunctival sac. The medication requires approximately 3 to 5 minutes, optimally, to absorb. Systemic effects of eye medications may be reduced if pressure is applied to the tear duct for one minute following the instillation.
The best practice is back to basics.
  1. What is the medication for?
  2. What is the expected outcome?
  3. Why the resident is receiving it?
  4. When is the medication is to be administered?
  5. Setup your cart and MAR before starting the medication pass;
  6. Concentrate on the resident while delivery their medication therapy.
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