A critical care nurse tries to catch up with her morning medications after her patients condition changes and he requires several procedures He is intubated , so she decides to crush the pills and instill them into his nasogastric (NG) tube In her haste to give the already-late medications, she fails to notice the Do not crush warning on the electronic medication administration record She crushes an extended-release calcium channel blocker and administers it throughthe NG tube An hour later, the patients heart rate slows to asystole, and he dies
Anxious and in pain, the patient leaves surgery with several I . V. intracranial pressure (ICP) monitor and lines in place. The I. V. The tubing used in the operating room and the intensive care unit (ICU) are different. The ICU nurse has mistaken the patient’s ICP drain for the central line and is rushing to get ready to inject morphine into it. She realizes she’s about to make a big mistake and she stops just in time.
A 12-year-old boy with a seizure disorder receives a prescription for primidone (Mysoline) from his doctor. The pharmacist accidentally fills the order with prednisone after misreading the doctor’s handwriting. The boy receives prednisone along with his anti-seizure drugs for four months, which results in steroid-induced diabetes. Medication mistakes like these can occur in any healthcare setting, resulting in the patient’s death from diabetic ketoacidosis because the diabetes is not recognized. Preventing Medication Errors, a seminal report from the Institute of Medicine published in 2006, states that these mistakes cause 1 injury per 1,000 prescriptions. 5 million Americans each year for $3. 5 billion in additional medical costs, lost wages, and lost productivity. (Click the PDF icon above to view sobering statistics.) )
The process of administering medication involves many complex steps, including the prescription, transcription, dispensing, and administration of medications as well as the observation of the patient’s reaction. At any step, a mistake could occur. Despite the fact that a lot of mistakes are made during the prescribing process, some are caught by staff members like pharmacists or nurses.
Administration errors account for 26% to 32% of total medication errors—and nurses administer most medications. Unfortunately, most administration errors aren’t intercepted. Recent technological advances have focused on reducing errors during administration. Ten key elements of medication use
Errors with medication can be caused by numerous things. The Institute for Safe Medication Practices (ISMP) has identified 10 crucial factors that have the biggest impact on how medications are used, noting that flaws in these factors can result in medication errors. The following are some of them: patient education, drug information, adequate communication, drug packaging, labeling, and nomenclature, medication storage, stock, distribution, and drug device acquisition, use, and monitoring, environmental factors, staff training and competency, and risk management. a patient’s information.
The first of the five rights of medication administration is accurate patient identification (the right patient). Name, age, birthdate, weight, allergies, diagnosis, present lab results, and vital signs are all necessary pieces of information about the patient.
Medication errors related to patient information can be decreased by barcode scanning the patient’s armband to verify identity. However, barcode technology initially lengthens the time it takes to administer medications, which might encourage nursing staff to find risky workarounds to get around this safety system. The barcode approach is also not foolproof; the patient armband could be lost, it could stop scanning, or the scanner’s battery could die. information about drugs.
Every caregiver must have access to accurate and recent drug information. Protocols, text references, order sets, computerized drug information systems, medication administration records, and patient profiles can all provide this data. communication that is adequate.
Miscommunication between doctors, pharmacists, and nurses is a major contributor to medication errors. There should be no communication barriers, and drug information should always be confirmed. Utilizing the SBAR method (situation, background, assessment, and recommendations) is one way to encourage effective communication among team members.
Poor communication accounts for more than 60% of the root causes of sentinel events reported to the Joint Commission (JC). In a 2001 case, a patient died after labetalol, hydralazine, and extended-release nifedipine were crushed and given by NG tube. (Crushing extended-release medications allows immediate absorption of the entire dosage.) As a result, the patient experienced profound bradycardia and hypotension leading to cardiac arrest. Although she was successfully resuscitated, shereceived the drugs the same way the next day. Clinicians had failed to communicate to other team members that her initial cardiac arrest had occurred shortly after she’d received the medications improperly. Drug packaging, labeling, and nomenclature
Healthcare organizations should ensure that all medications are provided in clearly labeled unit-dosepackages for institutional use. Packaging for many drugs looks similar. A tragic case stemming from such similarity occurred with heparin (one of the drugs on the JC’s “high-alert” list, meaning it has a high potential for causing patient harm). A few years ago, several pediatric patients received massive heparin overdoses due to misleading packaging and labeling; three infants died. As a result, the Food and Drug Administration and Baxter Healthcare (the heparin manufacturer) issued a lettervia the MedWatch program alerting clinicians to the danger posed by similarly packaged drugs. Baxter has since enhanced the labels on heparin and some other high-alert drugs; it now uses a 20% larger font size, tear-off cautionary labels, and different colors to distinguish differing drug dosages.
Medication products with names that are similar in appearance or sound but different in actuality can cause mistakes. 25,530 of these errors were reported between 2003 and 2006 to the Medication Errors Reporting Program, which is jointly run by the U.S. S. Pharmacopeia and ISMP) as well as MEDMARX (a database of adverse drug event reports). The JC mandates that healthcare organizations identify look-alike and similar-sounding drugs annually and have a process in place to help prevent related errors. Distribution, standardization, and storage of medications.
Many seasoned nurses recall the days when critical care units kept a stash of medications, which frequently resulted in duplication errors. The availability of floor-stock medications could be reduced, access to high-alert medications could be restricted, and timely distribution of new medications from the pharmacy could potentially prevent a great deal of errors.
Also, hospitals can use commercially available products to decrease the need for I.V. compounding medications and I.V. admixing. Use of preprinted order sets and standardized formularies can reduce errors, too. The Institute for Healthcare Improvement recommends standardized order sets and preprinted protocols for 75% of the drugs healthcare facilities use. These orders and protocols help clinicians promptly select correct dosing regimens, routes, andparameters while eliminating ambiguous abbreviations and the risk of misreading a prescriber’s handwriting.
Even when automated dispensing cabinets are stocked by technicians, mistakes can still happen. An automated dispensing cabinet was recently filled with the incorrect concentration of a premixed potassium chloride I by a technician, according to a recent error that was reported to the ISMP. V. solution. acquisition, use, and supervision of medical equipment.
Errors in medication administration may result from improper drug delivery device acquisition, use, and monitoring. Some delivery methods have inherent problems that raise the risk of errors. As an illustration, I used to. V. Even after being disconnected from the pump, the medication tubing continued to flow or infuse. So, either medication boluses or IV could be given to patients. V. solutions, some of which sometimes had negative effects. For instance, a patient taking nitroprusside may get a large infusion of the medication during the admission process if the I. V. The patient was moved from one bed to another after the tubing from the pump was taken out. This flaw in the design has since been fixed. I should not be compatible with syringes used to administer oral medications. V. tubing. elements of the environment.
Inadequate lighting, cluttered workspaces, elevated patient acuity, distractions during drug preparation or administration, and caregiver exhaustion are all environmental factors that can promote medication errors. By selecting the PDF icon up top, you can view The Fatigue Factor. ).
Distractions and interruptions can cause the clinician to lose focus, which can result in critical errors. The automated medication dispensing machines at Sentara Leigh Hospital in Norfolk, Virginia, have a no interruption zone set up around them. Staff members are aware not to interrupt a nurse who is using the machine to get medication.
Medication errors are also related to heavier workloads. The number of patients that a nurse is responsible for growing due to the nursing shortage has increased workloads. Additionally, nurses perform a variety of duties that keep them from being at the bedside of their patients, including taking phone calls, cleaning patients’ rooms, and delivering meal trays. Care for patients is directly impacted when nurses are not present at the bedside. Knowledge and skills of the staff.
Medication errors can be decreased with continued nursing staff education. New medications should have a high priority for teaching. A medication error that has happened at one facility is likely to happen at another, so staff members should be kept informed about both internal and external medication errors. (The heparin overdoses previously mentioned occurred at numerous institutions. ).
Staff members should have easy access to this information as medication-related policies, procedures, and protocols change. Nurses can also go to pharmacy grand rounds. Nursing grand rounds are now used in some facilities as a means of retaining staff members’ expertise. educating the patient
Patients should be taught the name of each medication they are taking, how to take it, the dosage, any possible side effects and interactions, how it should be disposed of, and the condition it is intended to treat. Risk management and high-quality procedures.
Establishing adequate quality processes and risk-management plans is the final strategy for reducing medication errors. Every facility needs to have a culture of safety that promotes open communication about medication errors and near-misses (errors that don’t affect patients). Effective systems-based solutions can then only be found and applied.
Simple redundancies can find and fix errors before they reach patients, such as using an independent double-check system when administering high-alert drugs. The Institute of Medicine asserts that companies with a strong culture of safety are those that encourage all staff members to be on the lookout for unusual events or procedures. repercussions for the nurse
The state board of nursing’s disciplinary action, job termination, mental anguish, and potential civil or criminal charges are just a few of the possible outcomes for a nurse who makes a medication error. Healthcare professionals who made fatal medication errors reported feeling paralyzed, uneasy, scared, guilty, and anxious in one study. Many people reported having trouble sleeping and losing confidence. prevention of medication errors.
Start by being diligent about performing the five rights of medication administration every time: the right patient (using two identifiers), the right drug, the right dosage, the right time, and the right route. This list has been expanded by some experts to include appropriate documentation, appropriate evaluation and monitoring, and appropriate justification for the drug.
Utilize the safety resources that are offered at your facility. Do not circumvent safety systems using workarounds. One-third of nurses in a 2008 study said they occasionally disregarded safety precautions. This was more common among nurses who worked in pediatrics and critical care, despite the fact that medication errors in these fields can have particularly severe consequences. When nurses routinely circumvent safety measures and develop workarounds, the employer is required to conduct a root-cause analysis to determine the cause of the workaround and take appropriate action to address the issue and prevent future occurrences.
Reading back and double-checking verbal or telephone medication orders are additional actions you can take to encourage safe medication use. (Click on the PDF icon above to view Reading back medication orders. (Asking a colleague to double-check your medications when administering high-alert drugs; using an oral syringe to administer oral or NG medications; checking patients for drug allergies before administering new medications; becoming familiar with your facility; and not using a list of abbreviations. The JC published a list of acronyms that should not be used because they can result in medication errors in 2004. For instance, in one recorded instance, a 9-month-old baby died from a fatal tenfold overdose of morphine due to a naked decimal point (one without a leading zero). The dosage was noted as being. 5 mg is represented as 5 mg. getting rid of medication mistakes.
Utilizing the right technology to help ensure proper procedures are followed and remaining vigilant are necessary to prevent medication errors. Computerized physician order entry eliminates poorly handwritten prescriptions, provides decision support regarding standardized dosing regimens, and identifies and alerts doctors to patient allergies or drug interactions.
The Leapfrog Group (whose mission is to trigger giant leaps forward in healthcare safety, quality, and affordability) supports computerized physician order entry as a way to reduce medication errors. Use of computerized physician order entry and barcodes may reduce errors by up to 50%.
However, computers can’t detect or prevent all errors. In a single close call, an I. V. Despite having a valid barcode (applied by the pharmacy), a bag of standardized diltiazem (Cardizem) solution (125 mg in 125 mL normal saline solution) was mistakenly labeled as an insulin drip. Thankfully, a perceptive ICU nurse identified the bag in her hand as a premixed solution and not a pharmacy admixture. She could see the manufacturer’s label when she turned it over.
Use the safety procedures that are already in place at your facility. Preparing and administering medications should be done without interruptions. Take every opportunity to educate yourself on the medications you administer and mistakes to avoid. (By selecting the PDF icon above, you can access websites that can assist you in avoiding medication errors. Remember that fatigue can contribute to medication errors as a final point.
a few references.
Union of Consumers. Error is Human, Delay is Deadly. May 2009. www. safepatientproject. org. February 1, 2010 access.
Center for Safe Medication Practices. Nurse Advice-ERR [Newsletter]: ISMP Medication Safety Alert. www. ismp. org. accessed on February 1st, 2010.
Becker SC, Cousins DD, and Hicks RW. data report for MEDMARX. A report was written in response to the Institute of Medicines’ call for action to examine the connection between drug names and medication errors. Center for Patient Safety Advancement, University of Maryland, Rockville S. 2008. Pharmacopeia
Kohn LT, Donaldson MS, and Corrigan JM, eds. Building a Safer Health System: Recognizing That Error is Human. 2000. National Academy Press, Washington, DC.
Koppel R, Wetterneck T, Telles J, and Karsh B Barcode medication administration system workarounds: how often they happen, why they happen, and how they endanger patient safety. J Am Med Inform Association 2008;15(4):408-423.
Dinges D., Scott L., Aiken L., Hwang W., Rogers A. nurses’ shift schedules and patient security in hospitals. (Millwood) Health Aff. 2004;23(4):202-212.
Sakowski, J., Newman, and K. severity of medication administration errors identified by a bar-code medication administration system. Am J Health Syst Pharm. 2008;65(17):1661-1666.
Visitwww. AmericanNurseToday. For a comprehensive list of all references, visit com/archives.
Pamela Anderson works as an adult nurse practitioner at Clarian Health in Indianapolis, Indiana, a resource pool float nurse at Ball Memorial Hospital in Muncie, Indiana, and a p. r. n. ICU nurse at the Tipton Hospital in Tipton, Indiana Terri Townsend is employed by Ball Memorial Hospital in the cardiovascular intensive care unit and the cardiac telemetry unit. She also serves as an adjunct clinical faculty member at Ball State University School of Nursing in Muncie. The organizers and authors of this CNE activity have not disclosed any material financial connections with any commercial entities related to this activity.
What if a nurse makes a medication error? : The only realistic course of action is to own up to the mistake and act morally by prioritizing the patient. Take immediate corrective action. Inform the patient’s physician of the error as soon as possible so that steps can be taken right away to counteract the negative effects of the misprescribed medication.
What action should be taken when a medication error occurs?
If you discover a medication error that someone else made, you must IMMEDIATELY NOTIFY THE RN CM/DN AND ADEQUATELY DOCUMENT THE ERROR. Your supervisor should also be informed in accordance with the agency policy.
What happens during medication error?
A medication error is defined as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer,” according to the National Coordinating Council for Medication Error Reporting and Prevention.
What are the possible consequences of medication error for the health professionals?
Loss of patient trust, legal action, criminal prosecution, and disciplinary action by the medical board are just a few of the effects that doctors may experience after prescribing errors.
Additional Question — What if a nurse makes a medication error?
Is a medication error considered neglect?
When a prescription differs from the doctor’s order, the manufacturer’s instructions, or the generally recognized industry standards for the medication, it is considered to have been administered incorrectly. Serious mistakes may constitute nursing home abuse or neglect.
Who is responsible for medication errors?
In short, anyone and everyone involved in the chain of prescribing and administering a medication can be held accountable for prescription drug errors. This includes medical professionals such as doctors and nurses, as well as facilities such as hospitals and hospital pharmacies.
What are 5 examples of common medication errors and their potential consequences?
Types of Medication ErrorsPrescription. Omission. improper time. drug not authorized. unsuitable dosage incorrectly prescribed/prepared doses. For example, administering the medication to the wrong patient, giving an extra dose, or administering it at the incorrect rate are all examples of administration errors.
What are the personal and legal consequences of medical errors on healthcare providers?
Following a medication error, a nurse may face disciplinary action from the state board of nursing, termination from their position, mental anguish, and potential civil or criminal charges.
What are the consequences of medication administration and errors which may occur?
Patient morbidity, mortality, adverse drug events, and lengthened hospital stays are all significant effects of medication administration errors. Additionally, it raises expenses for medical professionals and healthcare systems.
What might be the consequences if a health care professional misunderstood a doctor’s verbal or written orders for medication?
Therefore, if you misinterpreted the verbal order in any way (e.g. g. If you make a mistake (e.g., ordering the wrong medication or dosage) and the patient suffers harm as a result, you may be held accountable through a professional negligence lawsuit.
What is the most common medication error?
Dispensing the wrong medication, dosage strength, or dosage form; calculating the dose incorrectly; and failing to recognize drug interactions or contraindications are the three most frequent mistakes. Both the patient and the healthcare provider have the potential to make mistakes when administering medications.
What is breach of duty in nursing?
Breach of duty: Failure to provide a reasonable standard of care, as dictated by professional practice guidelines or what another nursing professional would offer in a comparable situation Damages: The patient suffered harm or injuries.
How common are medication errors in nursing?
In the United States, the FDA receives over 100,000 reports of medication errors each year. In hospitals each year, medication errors cause about 400,000 drug-related injuries.
What is the most common error in nursing?
#1 Errors with Medication For new nurses, the most common cause of errors with medication is a lack of ‘presence of mind’, as well as nerves and pressure. Studies have shown that administration errors can account for anywhere up to 32% of medication errors.
What nursing action causes most medication errors?
Poor doctor-to-patient communication is one of the most frequent causes of medication errors. You and your doctors’ lack of communication Medication names with similar pronunciations and similar-looking drugs.
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