...Running head: PRACTICE PROBLEM: MEDICATION ERRORS Practice Problem: Medication Errors Amy Courcier Grand Canyon University NRS-433 V Christine Thompson-Sanxter September 22, 2012 Career progression: preventing drug errors. Ashurst, A. (2008). Career progression: preventing drug errors. Nursing & Residential Care, 10(10), 498-501. Abstract: Making errors in drug administration can have serious consequences for the patient and the nurse involved. In the second of two articles Adrian Ashurst discusses the ways that risk can be minimized and drug errors prevented. Nurses' experiences of drug administration errors Schelbred, A., & Nord, R. (2007). Nurses' experiences of drug administration errors. Journal Of Advanced Nursing, 60(3), 317-324. doi:10.1111/j.1365-2648.2007.04437.x Abstract: This paper is a report of a study to describe the experiences of nurses who had committed serious medication errors, the meaning these experiences carry, and what kind of help and support they received after committing their error. Background. Medication administration is an important nursing task. Work overload, combined with increased numbers and dosages of medication prescribed, puts nurses at risk of making serious errors. A drug error has the potential for disastrous consequences for patients. What is sometimes disregarded is the effect on the nurse involved. The majority of research on nurses and medication errors is framed within biomedicine, law and management. Methods...
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...In the 1999 research studies began to review the problem of medical errors and how they occurred. Studies and reports, such as the Institute of Medicine IOM report in 1999, strongly suggest that most medical errors are related to systems and processes and not individual negligence or misconduct. The IOM report recommended that the key to addressing medical errors is to focus on improving the processes used to deliver healthcare and not placing blame on the individuals involved. Approximately 1.3 million people are injured annually in the United States following "medication errors". The FDA defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient”. The U.S. Food and Drug Administration (FDA) currently review medication error reports that come from drug manufacturers and through Med Watch, the agency's safety information and adverse event reporting program. The agency also receives reports about medication errors from the Institute for Safe Medication Practices (ISMP) and the U.S. Pharmacopeia. Some things the FDA has put into place to prevent medication errors: * Drug Name Review: To minimize drug name confusion, FDA reviews about 400 drug names a year that companies submit as proposed brand names. The agency rejects about one-third of the names that drug companies propose. * Drug Labels: FDA regulations require all over-the-counter (OTC) drug products (more than 100,000) to have a standardized...
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...1. Critical analysis of an issue in the clinical area a) My topic is Medication Error. b) I choose this topic because during my experiences in clinical area as well my experience in Hospital where I worked, I have came across different types of medication errors which involve patients and this could be a cause for serious problems to patients and in some cases will lead to death. It is a serious matter. Also drug error can have bad effect on nurses, both personally and professionally. C) Problems that I have identified regarding this topic ISSUE 1 In Medical ward, CRF and DM patient was advised to give injection Human Mixtard 10 units BD (10 units before breakfast and 10 units before dinner). And it was advised to give the injection 20 minutes before food. But the nurse who changes the treatment chart was mistakenly written injection Human Mixtard 10 units before breakfast and 20 units before dinner. The night dose was double. But luckily it was noticed by doctor during morning round. Otherwise nobody will recognize and will give the dose as it is. And will lead patient to a serious condition. ISSUE 2 While giving tablets through NG tube, I have noticed that some nurses throw the medication when it was difficult to pass through the tube. In this case patient will not get any effect of the prescribed medication. This a serious matter in which doctor will start new drugs daily because he will be thinking there is no response for the previous drugs. He does not know what...
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...From Medscape Nurses Medication Error Prevention for Healthcare Providers Faculty and Disclosures CE Information There are between 44,000 and 98,000 individuals who die every year in hospitals due to preventable medical errors.[1] It has also been reported that this is only part of the problem, as thousands of other patients are adversely affected by medical errors or barely avoid injuries that are nonfatal.[2] These medical errors not only cost the loss of lives, but carry a financial burden that is estimated to be in a range of $17 billion to $29 billion annually. Additionally, there is physical and psychological pain and suffering related to these errors.[1] Another consequence is that medical errors diminish trust and satisfaction in the healthcare system and in healthcare professionals.[1] Ginette A. Pepper, PhD, RN, FAAN, a Professor and Helen Lowe Bamberger Colby Presidential Endowed Chair and Associate Dean for Research, University of Utah College of Nursing, Salt Lake City, spoke on medication safety for the geriatric nurse practitioner (GNP).[3] Dr. Pepper was trained as a pharmacologist with a nursing focus. She was one of the first NPs to add "geriatric" to her title as well as one of the first NPs to have prescriptive authority. Safety Principles and the Medication Use Process Dr. Pepper noted that safety issues are of the utmost importance for all healthcare providers.[3] Nursing as a profession has a long history of regarding patient safety as a primary...
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...Medication Errors Stephanie Stephens January 9, 2016 NU1426 ITT TECH Nurses must always follow the six rights of medication administration thoroughly to ensure patient safety. These rights include right medication, right route, right time, right client, right dosage, and right documentation. When one of these rights is not followed a medication error has occurred and must be reported immediately. Medication error prevention is vital in the role of the nurse. There were many contributing factors leading to this medication error and there are many ways to avoid medications errors. Looking at the reasons why medications occur helps the nurse understand what areas to be most vigilant. The main areas of medication errors are distractions/ interruptions, medication education, interpretation of an order and poor calculations. Patients during their time in the hospital will receive medications. Distractions will occur throughout a nurses shift, losing concentration at the task at hand can lead to serious and harmful mistakes. It is important for the nurse to let her surrounding nurses know when she/he is pulling medications so that there isn't any distractions. Also, a quiet environment when taking telephone orders so that the order can be heard clearly and dictation from the provider is understood. Another medication administration error prevention for the nurse is to allow for delegation and to not take on to much. When a nurse is in the process of administering medication...
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...Medication errors that result in death, physical and/or mental challenges are inexcusable to the patients and their loved ones. There are several types of medication errors and prevention begins with recognizing the causes and developing possible solutions in order to limit the occurrences. Prevention of these errors is an immediate need considering the analysis that they are one of the leading causes of medical grievances in the United States. Infant Death In the case study, “Understanding the Causes and Costs of Medication Errors”, a medication error lead to the death of an infant who was one day old. There were more than fifty latent and active failures that occurred throughout the series of events that lead to the infant’s death that began with the pharmacists and ended with the nursing staff. The laws that were broken in this case weren’t in the hands of a single individual or component however; there were liable parties: nursing staff, pharmacist, manufacturer, physician, health department, and hospital administration. Laws Broken The administration of a medication act is when a single dose of a prescribed drug is given to a patient by an authorized person in accordance with the federal and state laws and regulations, (Pozgar, 2009). This law wasn’t adhered to by the nursing staff involved in this case. The unauthorized nurse practitioner altered the way the medication was prescribed to the patient by administering the medication through an IV instead of an...
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...Medication Administration Errors A medication error is commonly defined as a deviation from the physician’s medication order in the patient record or an error occurring in the medication-use process. (Choo, Hutchinson, & Bucknall, 2010, p. 854) The review of literature in the article “Nurses’ Role in Medication Safety” attempts to identify the challenges of medication safe delivery in the clinical practice by reviewing multiple studies. The article authors define two different approaches to viewing human errors in medication errors. The “person” approach focuses on the individual nurse making the error and focuses on the unsafe behavior related to inattention, forgetfulness, carelessness, negligence or recklessness. With this approach, errors are reduced by modifying human behavior. The system approach focuses on the working conditions and looks at errors as results of systems problems within the clinical setting, such as staff shortage, increased workload, interruptions etc. (Choo, Hutchinson, & Bucknall, 2010, p. 855) The system approach is more conducive to changing processes which contribute to errors instead of blaming the individual. Work environments are reported as being a major influence in medication errors. The authors cite a study by Sanghera et al. (2007) which states lighting, nurse interruptions, and poor communication amongst team members contribute to medication errors. Another study is cited as reporting increased workload for nurses as another cause of medication...
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...Medication Administration Errors A medication error is commonly defined as a deviation from the physician’s medication order in the patient record or an error occurring in the medication-use process. (Choo, Hutchinson, & Bucknall, 2010, p. 854) The review of literature in the article “Nurses’ Role in Medication Safety” attempts to identify the challenges of medication safe delivery in the clinical practice by reviewing multiple studies. The article authors define two different approaches to viewing human errors in medication errors. The “person” approach focuses on the individual nurse making the error and focuses on the unsafe behavior related to inattention, forgetfulness, carelessness, negligence or recklessness. With this approach, errors are reduced by modifying human behavior. The system approach focuses on the working conditions and looks at errors as results of systems problems within the clinical setting, such as staff shortage, increased workload, interruptions etc. (Choo, Hutchinson, & Bucknall, 2010, p. 855) The system approach is more conducive to changing processes which contribute to errors instead of blaming the individual. Work environments are reported as being a major influence in medication errors. The authors cite a study by Sanghera et al. (2007) which states lighting, nurse interruptions, and poor communication amongst team members contribute to medication errors. Another study is cited as reporting increased workload for nurses as another cause of medication...
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...Wrong-time Medication Administration Errors NUR 45200 Quality and Safety for Professional Nursing Practice May 1st, 2016. Patient Safety/Quality Improvement Statement and Chosen Cause that will Drive Improvement Wrong-time medication administration error has been identified as one of the major components of medication errors committed my health care professionals especially nurses. Several factors or causes are responsible for this error, but nursing factor will be discussed in this essay focusing majorly on medications pass time insufficiency and med pass rule of 30 minute. Nurses are directly involved in medication administration and they can play a huge role in preventing or reducing wrong-time medication administration error. Current Knowledge of the Patient Safety Concern/Quality Improvement Issue Wrong-time medication administration error is the most common type of medication errors committed by nurses. It can simply be defined as failure to administer medications 30min before or after the due due/scheduled time. The last element of the 5 Rights -- right time -- has often been governed by the "30-minute medication rule." For as long as many nurses can remember, every hospital, unit, and nurse has passed medications by this rule, which says that a medication is "on time" if it is administered 30 minutes before or 30 minutes after the scheduled administration time (although some hospitals have policies that allow a 60-minute, rather than a 30-minute, window). Such...
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...My involvement in the drug error is as follows. I was working on the night shift as the only qualified nurse with 2 nursing assistants. The late shift decided to administer the 10pm medications as a way of helping me. This however was key in me making the error that I did. If I had been left to do the 10pm medications by myself, this error would not have occurred. Patient PF was given her medication by the late staff, however she had spat them out. On going to give her these again, I also repeated her liquid medication which she had actually taken with the late shift before she spat out her tablets. PF took half the liquid before giving it back to me saying that she had already taken it and it was just her tablets that she didn’t take. She accepted the tablets no problem from me. I checked the BNF to see limits of medication and knew the extra that she had was well within the maximum dose. I also knew that she was not naive to medication and had been taking this medication for some time without any adverse effects. I checked her observations and BP, pulse and temp were all within normal limits. I continued with getting the other ladies ready for bed and carried on with my regular night time duties and once the ward was settled I filled in the datix form to report the error. It was at this time that I realised I should have notified someone earlier of the error. I contacted the AMART team as it was my understanding that they triage the calls to the duty doctor overnight. I...
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...Tragic Medication Errors: Accidental Abortions and Premature Birth Lynn Fernandez December 7, 2014 Professor Martinez Miami Dade College Tragic Medication Errors: Accidental Abortions and Premature Birth Medication errors within the healthcare system have become increasingly pervasive throughout the years yielding adverse effects to corresponding patients. Medication errors refer to an “unintentional significant reduction in the probability of treatment being timely and effective or increase in the risk of harm when compared with generally accepted practice” (Velo & Minuz, 2009, p. 624). These effects may vary from virtually no harm with minimal inconveniences to inexorable toxic fatality for the patient. This article focuses on a prescription error that mistakenly took the life of 11-month old Tranlya Sampson as her mother was prescribed a drug that is commonly used to force dead fetuses out of the mother’s womb as well as two unborn twins that lost their lives due to the same medication error in the same day. Due to this drug, Tranlya suffered brain damage and remains hospitalized due to health complications. A wrong medical decision made by a healthcare provider is a probable cause for medication errors, which can derive from a lack of knowledge or inadequate training. Lacking experience in the healthcare workforce or lack of skills to complete certain tasks can be associated with prescribing faults (Dean, Schachter, Vincent, & Barber, 2012). In a Florida...
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...Medication Safety Patient safety is the first priority concern for leadership in all health care organizations. The medication delivery process is the most common intervention in health care system. For that reason medication safety is considered the most challenging and complex process in improving patient care and safety during hospitalization. Medication-related errors are serious and occur at a rate of about one per patient per day (Allan, 1990). It is a harmful practice affecting patient’s health and life. Some of these errors may result in death or inefficiency of organs functions. In addition, medication errors may financially affect the health care organization due to long patient stay in the hospital for advanced treatment (Presto, 2004). This research paper will provide highlights on medication errors definition, importance of safety during medication process, factors contributing to medication errors and effective factors in preventing medication errors. Medication errors were defined as a fault in medication that may occur at any stage of the process in ordering or delivering medications (Bates, Boyle, Vliet, Scheider & Leape, 1995), either an injury occurred or the potential for injury was present (Bates et al, 1999). These errors could occur in dosing error, which is common (Lesar, Briceland & Stein, 1997), or wrong route, or wrong time, or error in medicine rate and omission error (O’Shea, 1998). Also there are some situations such as missing a dose of...
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.... There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration. Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing...
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...Medical errors have and continue to be an enormous problem in health care. Patients die from the wrong drug or wrong dosage, or perhaps an infection that could have been prevent with better hygiene practices. More attention was placed on the issue of medical errors in 2000 when the Institute of Medicine made available the well-known report titled “To Err is Human: Building a Safer Health System”. The report documented evidence of an estimated 44,000 people and as many as 98,000 people dying in hospitals from medical errors each year in the United States (IOM, 1999). Of the many medical errors, medication errors happen to be one that can not be overemphasized. Medication use have been found to account for at least 20 percent of adverse events in patients in hospitals. Out of every hundred medication orders, there is an occurrence of five adverse drug events (Tam, 2005). Malpractice claims due to adverse drug events can have negative effects on the hospital and the health care providers. The hospital and health care providers can have their reputation damaged, thousands of dollars are spent for the losses, there is time lost from work, not to mention the emotional stress involved (Rothschild et. al, 2002). The cost of preventable medication errors has been estimated between 17 and 29 billion dollars annually (Strohecker, 2003). As such, due to these alarming statistics, this paper focuses on some of the potential risks of medication errors, and some recommended interventions...
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...Abstract Healthcare unlike many high-risk industries has made slow progress in improving patient’s safety. The role of nursing in improving medication safety has been largely underestimated. Much of the research undertaken to date in relation to adverse medication events has neglected the impact that nurses have or could have in improving patient safety. In examining literature regarding adverse medication events one can see the urgent need for significant improvement in medication practices and processes. In addition that this health care issue will only improve with the participation of all disciplines working towards a common goal of improving the safety of those in our care. Introduction Medications play a key role in healthcare but can also be a significant key cause of medical error and of adverse patient outcomes. Nurses by the nature of their roles in medication administration can be the last line of defense in eliminating or reducing adverse medication events. The administration of medication is a common and almost routine activity in a nurse’s daily work, yet it is fraught with complexity and risk for both the patient and nurse. As a student nurse working in partnership with a registered nurse I have observed a variety of practices in medication administration that have varied from what I have been taught in class. On reflecting on these practices and questioning nurses why such practice has been adopted has illustrated to me both the flawed processes and environment...
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