OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Developmental Disabilities Services Division
P.O. Box 25352
Oklahoma City, OK  73125
(405) 521-3571 

DDSD #07-05

November 21, 2007

Dear Provider,

The DDSD Medical Services Unit is required by OKDHS policy to compile, review, and analyze data on medication events and make recommendations to the DDSD director and other appropriate program areas [340:100-5-33, Medication Events, subsection (g)]. Subsections (e) and (f) of that same policy require provider agencies to develop and maintain policies and procedures for the review and reporting of medication events and to correct identified problems with medication events.

Medication event analysis reports for 2005 and 2006 reveal that the most frequently reported medication events are related to missing doses of medication and incorrect documentation.

It has also been observed that a fairly large number of medication events have been reported on the Incident Report form 06MP046E (DDS-46) under the category of “other significant occurrence involving medication”. After reading the description of the event, a more appropriate category should have been chosen. DDSD encourages Medication Administration Technician (MAT) instructors and agency administrators to ensure that staff who might complete incident reports related to medication events are taught to select the correct category for each medication event.

In addition, it is recommended that internal MAT training and agency protocols be reviewed to determine if adequate emphasis is given to the importance of administering every dose of prescribed medicine as well as the importance of appropriate and accurate documentation.  If your staff receives their MAT training through a local technology center, a similar letter has been sent to the superintendents and MAT instructors of those facilities.

DDSD will continue to monitor medication events and provide additional data as it becomes available.  If further information is required, please contact Pamela Clark, DDSD State Nursing Director, or Michaela Bishop, DDSD Training Director, at (405) 521-6521, or toll free at 1-866-521-3571.

Sincerely,

James M. Nicholson, Director
Developmental Disabilities Services Division
Oklahoma Department of Human Services