Description
Determination of the type of medication or other substance event.
On-Screen Instructions
Select all that apply.Please submit “Incorrect patient” as “Incorrect medication or substance.”
Field Type
Checkbox (multiselect)Responses
Incorrect medication or substance
Patient death or serious injury associated with being given a medication or other substance that was not ordered for him or her, or was intended for another patient.
Includes
Medications intended for another patient; medication or other substance that was not ordered for patient
Excludes
Wrong graft tissue (submit as a “Surgical or other invasive procedure” event)
Medication not appropriate to the patient’s clinical situation (e.g., giving a patient with a drug resistant infection a drug in the family to which the infection is resistant) (submit as “Medication or other substance contraindicated”)
Includes
Excludes
Incorrect route
Patient death or serious injury associated with being given a medication or other substance through the incorrect route of administration.
Includes
Injection of medication or substance given instead of medication or substance being used for irrigation
Giving IM dose titrated through IV
Suspension medication given through PICC instead of PEG
Giving a suppository instead of tablet
Giving a patch instead of an IV
Excludes
Incorrect dosage form
Patient death or serious injury associated with being given a medication or other substance in the incorrect dosage form.
Includes
Sustained release instead of immediate release; giving tablet instead of liquid form
Excludes
Incorrect strength
Patient death or serious injury associated with being given a medication or other substance in the incorrect strength/concentration.
Includes
Concentrations that are too high or too low
Patient is given an “unmixed” antibiotic that was supposed to mixed with another substance
Patches applied that are the wrong concentration (e.g., Fentanyl patch 25mgm instead of 50mgm)
Excludes
Incorrect dose
Patient death or serious injury associated with being given a medication or other substance in the incorrect dose (i.e., too much or too little).
Includes
Giving too much or too little of a medication or other substance at once
Overdose
Underdose
Extra dose
Excludes
Omitted medication (submit as “Medication or substance omitted”)
Incorrectly discontinued medication (submit as “Medication or substance discontinued”)
IV medications given at an incorrect rate (submit as “Incorrect rate”)
Expired medication or other substance
Patient death or serious injury associated with being given a medication or other substance whose expiration date has passed.
Includes
Giving medications or other substances whose expiration date has passed
Using expired bone matrix admixture in a procedure
Excludes
Incorrect/incomplete labeling
Patient death or serious injury associated with being given a medication or other substance with incorrect or incomplete labeling.
Includes
Medication hung and infused but not labeled or documented
Excludes
Mislabeled blood products (submit as “Blood or blood product”)
Medication or other substance contraindicated (includes documented allergies and sensitivities)
Patient death or serious injury associated with being given a medication or other substance they should not have been given for a known, documented reason.
Includes
Patient given a medication or other substance, or a prescription for a medication or other substance, they should not have been given for a documented reason regardless of result
Drug-drug contraindication
Drug-food contraindication
Drug-disease contraindication
Drug-clinical condition contraindication
Drug procedure contraindication
Excludes
Medication or other substance omitted
Patient death or serious injury associated with not being given a medication or other substance that they should have received.
Includes
Prescribed medication not given for any reason, including incomplete medication reconciliation at intake or discharge and failure to process/enter medication reconciliation form
Giving epidural medication through a disconnected line; ordering a medication late that is not administered to the patient
Excludes
Medications that have been incorrectly discontinued (submit as “Medication or substance discontinued”)
Allergic reaction due to unknown allergy
Patient death or serious injury associated with being given a medication or other substance for which an unanticipated allergic reaction occurred either in the facility or at home and reported to facility post-discharge.
Includes
An inappropriate immune response, such as a rash or hives, as a result of medication administration
Anaphylaxis as a result of medication administration
Excludes
Allergic reactions due to documented allergies (choose “Medication or substance contraindicated”)
Adverse reaction not due to allergy or known contraindication
Patient death or serious injury associated with being given a medication or other substance (at normal dosage during normal use) for which an adverse reaction occurred that was not due to an allergy or known contraindication.
Includes
Anticholinergic reaction syndrome as a result of medication administration
Severe hypotensive event as a result of medication administration
Metabolic reactions
Other reactions that cannot be classified as an allergic reaction
Excludes
Unanticipated allergic reactions (submit as “Allergic reaction”)
Documented allergies or sensitivities (submit as “Medication or other substance contraindicated”)
Oversedation (submit as “Oversedation”)
Drug interaction
Patient death or serious injury associated with an unanticipated drug interaction.
Includes
Ordered medications in hospital interacting with recreational drugs
Excludes
Drug interactions due to contraindications
Oversedation
Patient death or serious injury associated with one or more medications that result in a level of sedation greater than the desired therapeutic level of sedation.
Includes
Oversedation associated with medications after the patient has left the PACU
Excludes
Oversedation associated with anesthesia during the operative period and prior to discharge from the PACU (submit as “Anesthesia”)
Includes
Excludes
Patient counseling omitted
text
Includes
Excludes
Incorrect quantity, amount or size
text
Includes
Excludes
Medication taken incorrectly
text
Includes
Excludes
Generic substitution
text
Includes
Excludes
Brand substitution
text
Includes
Excludes
Other (please describe)
Patient death or serious injury associated with being given a medication or other substance not otherwise included in the above categories.
Includes
Placing epidural needle in subarachnoid space instead of epidural space
Patient non-compliant with medication discontinuation instructions prior to surgery
Incorrect prescription sent home with patient
Transcription error on discharge medication schedule
Incorrect preparation, including inappropriate cutting of tablets, error in compounding, mixing, etc.
Incorrect patient/family action (e.g. self-administration error)
Excludes
Invasive incorrect site medication administration (submit as “Surgical or other invasive procedure event (wrong site)”)
Guide for Use
In keeping with NQF, hypoglycemia is considered a harm resulting from a medication event.
How do I classify my medication-related adverse event?
Adverse events involving medication have several possible classifications. If the patient has a known, documented allergy or sensitivity, the event is Medication or substance contraindicated. If the patient has an allergic reaction but no known, documented allergy or sensitivity, the event is an Allergic reaction due to unknown allergy. If the patient has a reaction other than an allergic reaction and no known, documented allergy or sensitivity, the event is an Adverse reaction not due to allergy or known contraindication. Please note: Medication or substance contraindicated can also refer to clinical contraindications (e.g., pregnancy is a contraindication for the administration of tetracycline).
Example A) Patient with known penicillin allergy given dicloxacillin suffers no reaction
Medication or substance contraindicatedExample B) Patient with no known allergies given a medication and suffers hives and mild throat swelling
Allergic reaction due to unknown allergyExample C) Patient with no known allergies given a medication and has a severe hypotensive event
Adverse reaction not due to allergy or known contraindication
History
Start Date | Summer 2013 |
|---|---|
End Date | n/a |
Change History | n/a |