Medication Error Process

What happens when I make or discover a medication error?

-Staff should notify the nurse (Call house nurse M-F 9am-5pm, any other time call Nursing E-Cell)
-Staff and nurse will resolve/fix the error
-Staff who found the error will contact the staff to clarify the details of the error
-Staff who found the error will complete a medication error report on Netsmart within 24 hours of finding it

House Nurse and Program Manager Follow-Up

-The house nurse will assign points based on the Medication Error Points Sheet
-The nursing team will email individuals weekly to notify them that they have received a medication error and how many  total medication error points they have earned
-House nurse and Program Manager will review each medication error on Netsmart
-Every week the Nursing Department will send the Program Directors and Program Managers a list of Hammer staff who have medication errors and their total number of points

When a Staff Member Reaches 7 Total Points, The Staff May:

-Set up a meeting with their nurse at the primary house where the staff works. This meeting will be at a mutually agreed upon time
-The nurse will observe the staff perform one complete morning or afternoon medication pass (all the medications due for one individual). Based on the nurse’s judgement the staff may need to complete more than one medication pass
-If the staff completes this medication pass with zero errors, the staff will then be eligible to have three points erased from his or her total medication error point score

What Happens When a Staff Reaches 10 Points?

-Staff may continue to pass medications after 10 points, unless otherwise specified by the nurse, Program Manager, or Program Director.
-Staff must complete the Introduction to Health, Medication 101, and Activities of Daily Living classes within 30 days. The complete course takes two days and is offered twice a month
-Meet with the Program Manager and complete two supervised medication passes at the house
-Meet with a nurse and complete a third medication pass at Hammer Central Office

Contact Brandon Eddy at for more information.