MEDICATION PASS OBSERVATION REPORT * ERROR TYPE CODES 1. Omissions 5. Wrong Dosage Form
(Drugs ordered but not administered at least once) 6. Wrong Drug 2. Unauthorized Drug 7. Wrong Time
(Drugs administered without a physician’s order)
8. Mfg. Specs. and/or 3. Wrong Dose Professional Standard (below) 4. Wrong Route of Administration ERROR TYPE * RESIDENT DRUG/DOSE AS PASSED CURRENT DRUGS AS ORDERED TOTAL NO. OF MEDS PASSED TOTAL NO. OF DRUGS ORDERED ERROR GRAND TOTALS PAGE ERROR TOTALS
See explanation on reverse for error types and examples of significant andnon-significant errors (S/NS)
CUMULATIVE ERROR TOTALS Type 8 = Medication Errors Due to Failure to Follow Manufacturers Specifications or Accepted Professional Standards (check each that was observed) (The pharmacist is responsible for supporting any cited errors of Accepted Professional Standards with contemporaneous literature and/or facility policies.)
□ Failure to “shake well” products so labeled. □ Failure to properly mix insulin suspensions (e.g., “rolling”) without creating air bubbles.
□ Crushing tablets or capsules where manufacturer states “do not crush” [Exceptions - (a) if MD explains in the clinical record why crushing will not adversely affect patient, or; (b) if Facility
can provide manufacturer or professional literature to justify why modification of dosage form will not compromise patient care]
□ Failure to administer adequate (i.e., 8 oz) fluids with medications when manufacturer so specifies (e.g., with administration of bulk laxatives, NSAIDs or solid/liquid potassium supplements). □ Failure to administer medications with food or antacids when so specified by manufacturer (either before or with medication). This is especially important with NSAID medications. □ Administration of medications immediately before, during or immediately after administration of enteral nutritional formulas (ENFs) without, as a minimum,
(1) checking placement of nasogastric or gastrostomy tube (cited under F281);
(2) pre- and post-flushing of tube with at least 30 ml of preferably warm water (cited under F332/F333).
NOTE - if Dilantin (phenytoin) is being given immediately before, during or immediately after ENF, check clinical record to assure patient is not experiencing loss of seizure control or sideeffects such as sedation.
□ Failure to properly administer ophthalmic products wherein either (a) contact of the product with the eye occurs, or; (b) insufficient time (3-5 minutes) is allowed between administration of
□ Allowing resident to swallow sublingual tablets. □ Failure to properly administer medication via metered dose inhalers (MDIs). Proper administration includes: (a) shaking MDI well; (b) positioning MDI 2 finger widths in front of resident’s
mouth (or using spacer); (c) having resident exhale first then take a slow, deep breath as MDI is activated; (d) holding breath for a count of 10 after inhalation before slowly exhaling, and;(e) waiting a minute between puffs if multiple puffs are ordered.
NOTE - if resident is unable to cooperate with the above procedures (e.g., due to dementia) this should not be considered an error.
□ Other (please explain including potential for resident’s discomfort or jeopardy to his or her health and safety). _____________________________________________________________
□ ___________________________________________________________________________________________________________________________________________________□ ___________________________________________________________________________________________________________________________________________________□ ___________________________________________________________________________________________________________________________________________________
NUMBER OF ERRORS OBSERVED CALCULATED ERROR RATE OPPORTUNITIES FOR ERRORS
(Doses Given + Doses Ordered But Not Given)
2001 MED-PASS, Inc. (Revised April 2007)
The following numbers represent the error types coded on the front of this form. ERROR TYPE CODES (1 through 7) S - SIGNIFICANT NS - NON SIGNIFICANT 1. OMISSIONS (Drugs ordered but not administered at least once) 4. WRONG ROUTE OF ADMINISTRATION Administered 5. WRONG DOSAGE FORM Administered 2. UNAUTHORIZED DRUG (Drugs administered without
** (Park Davis Kapseals have an extended rate of
absorption. Prompt phenytoin capsules do not)
6. WRONG DRUG Administered 3. WRONG DOSE Administered 7. WRONG TIME Administered DEFINITION Medication Error – the preparation or administration of drugs or biologicals which is not in accordance with:
(1) physician’s orders:(2) manufacturer’s specifications (not recommendations) regarding the preparation and administration of the drug or biological;(3) accepted professional standards and principles which apply to professionals providing services. Accepted professional
standards and principles include various practice regulations in each State, and current commonly accepted health standardsestablished by national organizations, boards and councils. Significant Medication Error means one which causes the resident discomfort or jeopardizes his or her health. Criteria for judging significant medication errors as well as examples are provided above. General Rules for Determining Significance. – The relative significance of medication errors is a matter of professional judgement. Observers who are responsible for assessing these requirements must be qualified to exercise such judgement (e.g., pharmacists, nurses). Follow three general rules in determining whether a medication error is significant or not: • RESIDENT CONDITION – The resident’s condition is an important factor to take into consideration. For example, a potent
diuretic erroneously administered to a dehydrated resident may have serious consequences but if administered to a resident with a normal fluid balance may not. If the resident’s condition requires rigid control, a single missed or wrong dose can be highly significant. • DRUG CATEGORY – If the drug is from a category that usually requires the resident to be titrated to a specific blood
level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especiallyimportant with a drug that has a Narrow Therapeutic Index (NTI) (i.e., a drug in which the therapeutic dose is very closeto the toxic dose). Examples of drugs with NTI are as follows: Anticonvulsant: phenytoin (Dilantin), carbamazepine (Tegretol), valproic acid (Depakote); Anticoagulants: warfarin (Coumadin), Antiarrhythmic: digoxin (Lanoxin); Antiasthmatics:theophylline (TheoDur); Antimanic Drugs: lithium salts (Eskalith, Lithobid). Examples of drug categories which require titration of resident blood levels include anticonvulsants, anticoagulants, antiarrhythmic, antianginal, and antiglaucoma agents. • FREQUENCY OF ERROR – If an error is occurring with any frequency, there is more reason to classify the error as
significant. For example, if a resident’s drug was omitted several times, as verified by reconciling the number of tablets delivered with the number administered, classifying that error as significant would be more in order. This conclusion maybe especially valid when taken in concert with the resident’s condition and the drug category.
Operational Policy and Procedure Manual
2001 MED-PASS, Inc. (Revised April 2007)
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Good NEWS for those trying to quit smoking!! Beginning in September 2011, not only are Champix® and Zyban® covered by ODBF, but pharmacists are being reimbursed for their role in counseling and support of patients who are addicted to cigarettes. Details • People taking Champix® (varenicline) or Zyban® (bupropion) are now covered by limited use code 423 for 12 weeks a year, provided t
MEDICATION PASS OBSERVATION REPORT