MEDICATION ERRORS(Mistakes, Slips and/or Lapses)

MistakesError in planning and/or taking action.

Knowledge based: Unfamiliar with policies and

procedures Operating out of scope of

practice

Rule based: Not implementing Five Rights of

Medication Administration Operating outside agency Policies

and Procedures

Slips & LapsesError in executing correctly planned

actions.

Action based: Failure to maintain/stock/secure

prescribed medications. Not performing Five Rights of

Medication Administration.

Memory based: Adequate & Timely documentation. Following up on

physician/client/pharmacy requests

Identified Mistakes Unaware of agency policies and

procedures for med administration Unaware of indicators for post

administration observationo Allergic Reaction o Contraindications

Identified Slips & Lapses Missed Dose Wrong administration

technique/time Administering discontinued

medication Administering expired medication Transcribing verbal order in wrong

patient’s chart Documenting on wrong patient Meds administered based on

invalid lab results

ERRORWhen intended action is not performed.