Nurse Perception Of Medication Errors Case Study

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Appendix 1
Nurse Perception of Medication Errors
Modified Gladstone 2001

Why Do You Think Medication Errors Occur?

1. The following ten statements are all possible causes of medication errors. Please read them carefully and Rank #1 to #10. (#1 is the most frequent and #10 the least frequent). a. Drug errors occur when the nurse fails to check the _______ patient’s name band with the Medication Administration Record (MAR.)

b. Drug errors occur when the physician’s writing on the _______ doctor’s order form is difficult to read or illegible.

c. Drug errors occur when the medication labels/packaging _______
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Drug errors occur when there is confusion between two _______ drugs with similar names.

e. Drug errors occur when the physician prescribes the ________ wrong dose.

f. Drug errors occur when the nurse miscalculates the dose. ________

g. Drug errors occur when the nurse sets up or adjusts an ________ infusion device incorrectly.

h. Drug errors occur when nurses are confused by the ________ different types and functions of infusion devices.

i. Drug errors occur when nurses are distracted by other ________ patients, coworkers or events on the unit.

j. Drug errors occur when nurses are tired and exhausted. ________

2. In your estimation, what percentage of all drug errors are reported to the Nurse Manager by the completion of an incident report? (Please make an X on the line that corresponds most closely to your estimation.)

1% ________________________________________________________100 % (1.11)

NURSES’ PERCEPTIONS ABOUT MEDICATION ERRORS:

It is not always clear to nurses whether what they view as a minor drug discrepancy should be reported as a medication error. In the following examples you are asked to
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Whether or not a medication error occurred.

b. Whether or not the physician should be notified.

c. Whether or not an incident report should be completed.

Please answer “YES” or “NO” for each of the following statements:

3. A patient misses his midday dose of oral ampicillin because he was in X-Ray for three hours.

a. Drug Error Yes No

b. Notify Physician Yes No

c. Incident Report Necessary Yes No

4. Four patients on a busy surgical unit receive their 6:00pm doses of IV antibiotics 4 hours late.

a. Drug Error Yes No

b. Notify Physician Yes No

c. Incident Report Necessary Yes No

5. A patient receiving TPN feeding via an infusion pump is given 200 ml/hr instead of the correct rate of 125 ml/hr for the first three hours of the 24-hour infusion. The pump was reset to the correct rate after the change of shift at 7:00am when the oncoming nurse realized that the pump was set at the incorrect rate.

a. Drug Error Yes No

b. Notify Physician Yes No

c. Incident Report Necessary Yes No

6. A patient admitted with status asthmaticus on 08/13/97 at 2:am is prescribed ventolin nebulizers every four hours. The nurse omits the 6:00am dose on 08/13/97 as the patient is

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