...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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...UNDERSTANDING EVIDENCE - BASED NURSING | Evidence-based Literature Search and Review on Interruptions during Drug Rounds | Cohort: March 2010 | | Student ID: | | Word count: 3292 Additional Module 1 | It is generally accepted that evidence-based practice (EBP) is the way forward in contemporary nursing. It provides the rationale behind nursing practice and allows for the delivery of optimal nursing care. Evidence-Based Nursing (EBN) involves the process of researching and implementing proven evidence in providing better patient care and is crucial as the role of the nurse is ever expanding (Banning, 2005). This essay will demonstrate that as a student nurse, the author has gained the necessary skills to conduct an evidence-based literature search and review and implement that knowledge into practice. Starting with a brief discussion on EBN it will go on to identify a suitable research question. During a placement on a medical ward the author noticed that nurses experienced many interruptions whilst conducting medication rounds and this review will consider ways to minimise interruptions and thus improve patient safety. Using the PICO acronym a suitable research question was formulated, ‘do interruptions during medication rounds increase the drugs administration errors made by nurses?’ A short description of the literature search is given and a summary of findings is presented in tabular form. Five original articles were selected and one chosen to critically...
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...hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence. The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection Control. The goal of these four focus areas is safety. The goal of safety is the most important because it allows for the best management and treatment of patients. This will guide the hospital’s focus toward the best protocols and policies which will reduce patient harm and errors. Each policy and protocol is specifically designed for each individual facility. Medication Management is the focus area in which I chose to discuss the existing compliance of the organization. The Joint Commission’s ethics for medication management address the critical processes involved and support compliance with the National Patient Safety Goals. “The medication management standards are geared to allow assessment of the organization’s eight essential medication processes” (Manniello, 2011). The eight processes are critical to patient safety and include: planning, selection of medications, proper storage, ordering and receiving, preparation, administration, patient monitoring, and evaluation. Focus will be on the areas which did not meet the Joint Commission ethics and standards. a corrective action plan that will then be suggested to bring the...
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...Literature Search Paper NUR443 September 19, 2011 Professor Dina Faucher Literature Search Paper Numerous studies have been conducted to prove the relationship of shift work and fatigue and the results noted on medication errors. Two articles were chosen using the University Library, a qualitative research study and a quantitative research study from peer reviewed articles through the use of databases such as EBSCOhost, ProQuest, and Gale Powersearch. To research this topic, the query tool utilizing terminology such as shift work, fatigue, and medication errors was used to narrow the search. The intent of this paper is to identify the difference between research study articles versus plain journal articles, the type of nursing journals, and if the article is peer reviewed. EBSCOhost allows one to narrow the search, by selecting the mode as Boolean search, the source type as Academic Journal, the subjects as errors and patient safety, the publication as Journal of Nursing Management, AORN Journal, and Journal of Nursing Education, and finally the database as CINAHL plus with full text reduced the results to 259 articles. The articles are in order from most relevant to least relevant. Effects of working conditions of intravenous medication errors in Japanese hospital, written by Seki and Yamazaki was the most relevant article posted that encompassed the use of a quantitative research method to support the educational content. According to Burns and Grove (2011) “quantitative...
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...that such chronic shortage of nurses has a direct and negative impact on patient care (Bae, 2010; Bae, 2012b, Bae, Brewer, & Faan, 2012). For example, in several of her research articles, Bae (2010, 2012a, & 2012b) cited several research articles where researchers have found that the long hours worked by RNs are at the root of many adverse patient outcomes. Anecdotal evidence should suggest that anyone working long hours over an extended period of time will experience fatigue and decreased working performance. However, the health care system, as a whole, has not adopted the recommended standards from the Institute of Medicine (IOM) of “no more than 12 hours in a 24-hour period and no more than 60 hours in a 7-day period to avoid error-producing fatigue” (Bae, 2012a, p.60). The logical question is why not? Additionally, it...
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...html Errors that occur earlier in the medication process are more readily detected (~50% are prevented during the ordering stage) while very few (< 2%) are caught at the administration stage (bates et al., 1995). further, it has been noted that more than one third of medication errors occur at the latter stage (leape et al., 1995). because of the relatively high proportion of errors and the lack of success preventing them, error reduction strategies targeted at the administration stage High rates of preventable medication errors have been repeatedly reported in studies in the medical literature (Bates et al., 1995; Leape et al., 1995; Flynn et al., 2002; Kanjanarat et al., 2003). It is difficult, however, to cite a single number to define the extent of the medication error problem due to differences in institutions, study methodologies, error definitions, and other variables. On the high end of estimates, one study that compiled data from 36 institutions reported 19% (~1 in 5) of the medication doses studied over a 4-day period involved medication errors (Barker et al., 2002). These errors included wrong time (43%), omission (30%), wrong dose (17%), and unauthorized drug (4%). The number of these errors deemed potentially harmful adverse drug events (ADEs) was 7%. A comprehensive review of medication error studies cited in the Institute of Medicine (IOM) 2000 report on errors in the U.S. healthcare system suggests that preventable ADEs, i.e., harmful medication errors, occur...
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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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...organizations experienced any incidence of adverse drug events and medication errors. If so, why were these errors happening and how to does the data compare to other countries in the surrounding areas in addition to the United States. Two physicians were involved to determine the incidents. Data was gathered from Western countries but not world wide. Another reason to do the research was the increase in patient safety. ➢ How is the literature review used in the research? Literature/data was retrieved from other Western countries and the United States. Comparison with JADE study (Japan Adverse Drug Events) done by Bates DW in 1995 as well as including the research done for global patient safety also done by Bates DW in 1995. ➢ What are the ethical considerations for data collection? Data was gathered from several different subject selections (ages and genders); appropriate staff was involved (physicians who were qualified); names were kept anonymous to protect patient confidentiality; staff was aware of the research ➢ What is the data telling us in terms of statistical analysis? The data concluded that the different hospital units had different incidences of adverse drug events and medication errors. Data also determined the patient’s length of stay as an inpatient would also increase the chances of medicine errors. ➢ Which statistical methods were used in the study...
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...patient‘s understanding of their medication and their use is an important factor in Hospital Consumer Assessment of Healthcare Providers Patient Satisfactory Experience (HCAHPS) and is also driving patient safety and quality. Improving patient safety and quality about the use of medications, especially after hospital discharge, is a national concern. The discharge and the period immediately following can be a vulnerable time for patients putting them at increased risk for medication error and non-adherence to their medications. Comprehensive discharge instructions are essential to a smooth transition from the hospital to home. Because, most organizations do not have a standard discharge process there are not adequate safety measures to ensure quality –post discharge care. Therefore, many patients go home without a clear understanding about their discharge instructions especially their medications. Patients with a lack of understanding about their plan of care usually do not buy in to the importance of following that plan or adhering to the medication schedule; therefore, they do not actively participate or manage their health. An essential part to any...
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...Introduction 1 Literature review 2 Problem analysis and discussion 3 Electronic Health Records (EHR): 4 Computerized physician order entry (CPOE): 8 Conclusion 9 Recommendation 10 References 11 Introduction The healthcare industry is undergoing a drastic change in the modern world where the imprints of information technology (IT) are expanding and the combination of these two industries is leading to a new era of computerized hospital information systems. Baker (2008). The importance of information technology cannot be over emphasized for two major reasons, first, where a high level of accuracy is required (which can be fulfilled by digital mediums) and second, where a large size of transactional data exists and the requirement of analyzing this data supersedes (which can be fulfilled by having large databases and analyzing them using IT tools). There are numerous IT based applications in the environment and it has really become a challenge for the CTO of a healthcare facility to decide over the progressive plan for adoption of IT based systems in the purview of health information technology (HIT), computerized physicians order entry (CPOE), electronic health record (EHR) and many other similar programs found across the world. The primary question raised against any kind of IT investment is “how the proposed IT system will improve productivity, tender financial benefits and achieve administrative excellence?” There exists a rich literature on the analysis...
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...Prevention of Medication Errors in Nursing Practice Breton Sloop NU 332 Foundations of Nursing November 11, 2015 Teresa Faust Mary is a critical care nurse at a busy urban hospital, who is trying to catch up on her morning medication administrations. Her patient had required several procedures that morning, due to an alteration in his condition, and now Mary is behind schedule. The patient is intubated, so she decides to crush the pills, and administer them through his nasogastric tube. The patient’s medication is already late, but in her dash to give the medication as quickly as possible, she fails to notice the “Do Not Crush” warning on the electronic medication administration record (MAR). She then crushes an extended-release calcium...
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...The research conducted in this study focuses on how medication errors and how they are caused by doctors not being educated and trained in medical colleges about the administration and prescribing of medicine. The other problem shown in this article is that colleges within the United Kingdom are showing a lack of these special educational studies in medicine. The problem of the study is very important to Administrators because patient safety is one of the main priorities in any health care facility. Administrator overlook the progression of patient care and by seeing this study about medication errors, this should grab their attention. By knowing that doctors are not properly prescribing medications to patients, administration can take a deeper look into their faculties and makes sure all professional health care providers are up to date and fully trained in the process of prescribing medicine. The purpose of this study is to bring strong insight in the reader. Also, readers must realize that medication error dangerous and that they can happen anywhere. Not all doctors have the full education they need in prescribing medication to them. The research deals mostly on the research of the lack of education and training in medical colleges and how it influences poor medication errors. After reviewing the study, the main research question would be what causes medication errors and how can it be fixed? There are more than one hypotheses of this study. After reviewing the possible...
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...HSA 300 November 12, 2013 Incident Reports and Errors in Health Care Millions of people are injured yearly due to medical errors in the health care industry. Moreover, with the many errors that exist, it can cost billions of dollars each year increasing health costs. There are many examples of medical errors that take place within hospitals, but the most common and frequent error is due to medications. Many people believe medication errors are the result of abbreviations handwritten by physicians. Medical errors are a global issue and although, it is the most common, it can be the most preventable (Null et al. 2009, 56) As stated in “Death by medicine”, it found that 18-28% of people who were recently ill had suffered from a medical or drug error in the previous two years (Null et al.2009, 48). The affects of these errors lead to lost wages or productivity cost of employees. A medication error can easily take place if correct measures are not followed. For example, administering the incorrect medication or dosage amount to the wrong patient can be of great concern, which can result in long term injuries based on the depth of which the error resulted from. According to the American Association for Justice, the Institute of Medicine (IOM) preventable medical errors study estimated that at least 98,000 people die yearly totaling 29 billion dollars, which could have been prevented (www.Justice.org). In the past, errors were revealed primarily through a morbidity and mortality...
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...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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...The Benefits and Challenges of Computerized Physician Order Entry (CPOE): How are physicians affecting implementation? Executive Summary: Physicians have always been the driving force behind the success of new technologies and their effects on healthcare. They are interested in new ways of providing care by utilizing medications or trying new procedures and medical devices. Through research they seek to understand the human body and find cures for the diseases that attack it. They spend years in school and incur debt in upwards of $200,000 dollars before they graduate and have the opportunity to practice independently. Confronted with technology that can improve patient safety by up to 95% and save billions of dollars, they resist change. In the U.S. less than 10% of hospitals and less that 25% of physician offices have fully functioning CPOE systems. Cedars Mt Sinai pulled the plug on their multi-million dollar CPOE system, as did 6 other hospitals because physicians refused to use them. A review of the literature shows that approximately 68% of physicians surveyed identify CPOE as the solution to preventing many medical errors, adopting best-clinical-practices and reducing healthcare costs by billions of dollars annually. It also shows that physicians have issues and concerns with adopting CPOE and until hospitals and government regulatory bodies are ready to, not only address, but solve them, CPOE has little chance of being successful any time soon. ...
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