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A study on causes of medication error
A study on causes of medication error
A study on causes of medication error
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Background It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012). Medical errors can happen in the healthcare system such as hospitals, outpatient clinics, operating rooms, doctor’s offices, pharmacies, patients’ homes and anywhere in the healthcare system where patients are being treated. These errors consist of diagnostic, treatment, medicine, surgical, equipment calibration, and lab report error. Furthermore, communication problems between doctors and patients, miscommunication among healthcare staff and complex health care systems are playing important role in medical errors. We need to look for a solution which starts changes from physicians, nurses, pharmacists, patients, hospitals, and government agencies. In this paper I will discuss how does the problem of medical errors affect our healthcare delivery system? Also how can these medical errors be prevented and reduced? Define the problem Most medical errors come from human errors. Before defining medical error, we should have a good understanding of human error. As a human in our everyday life we are prone to make mistakes such as using ointment... ... middle of paper ... ...d8c29788%40sessionmgr111&hid=107&bdata=JkF1dGhUeXBlPXVybCxjb29raWUsaXAsdWlkJnNpdGU9ZWRzLWxpdmU%3d#db=bth&AN=80444360 http://www.iom.edu/reports/2006/preventing-medication-errors-quality-chasm-series.aspx http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf http://www.ihi.org/education/ihiopenschool/resources/Pages/AudioandVideo/PerspectivesTheMistakePart2.aspx http://www.ahrq.gov/consumer/20tips.htm http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/ http://www.nlm.nih.gov/medlineplus/patientsafety.html http://medicaleconomics.modernmedicine.com/medical-economics/news/using-ehrs-bring-innovation-rural-practice?page=0,1 http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html http://www.wmich.edu/wmu/news/2005/06/021.html http://www.msnbc.msn.com/id/6237364/
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
In the essay “When Doctors Make Mistakes” written by Atul Gawande, he writes a first-hand account of mistakes made by himself and his colleagues. The essay is divided into five parts, each named to the narrative and emotions of the story he would tell. In each story he tells, he uses such vivid language that we as readers feel as if we are one of his colleagues. Each section has its own importance to the whole point he was trying to get across, ““All doctors make terrible mistakes” (657).
I have been aware of medical errors for some time now. While in nursing school I have heard many stories from classmates and instructors of instances where people they knew, or loved ones had been either harmed or died because of a medical error. I have had experiences with medical errors. When I was in the hospital for the birth of my first child, the nurse that came to change out my IV bag did not check the
Over the past several years extended work shifts and overtime has increased among nurses in the hospital setting due to the shortage of nurses. Errors significantly increase and patient safety can be compromised when nurses work past a twelve hour shift or more than 40 hours a week. Hazardous conditions are created when the patient acuity is high, combined with nurse shortages, and a rapid rate of admissions and discharges. Many nurses today are not able to take regularly scheduled breaks due to the patient work load. On units where nurses are allowed to self-schedule, sixteen and twenty-four hour shifts are becoming more common, which does not allow for time to recover between shifts. Currently there are no state or federal regulations that restrict nurses from working excessive hours or mandatory overtime to cover vacancies. This practice by nurses is controversial and potentially dangerous to patients (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Burnout, job dissatisfaction, and stress could be alleviated if the proper staffing levels are in place with regards to patient care. Studies indicate that the higher the nurse-patient ratio, the worse the outcome will be. Nurse Manager’s need to be aware of the adverse reactions that can occur from nurses working overtime and limits should be established (Ford, 2013).
There are a few types of medical errors discussed in Patient Safety Principles & Practice. One of them is an error of execution. An error of execution is when a correct action does not proceed as intended. It is a failure of a planned action to be completed as first intended. It occurs unintentionally during an automatic performance of patient care. This error is almost always observable at the patient and caregiver interface.
In “When Doctors Make Mistakes,” Atul Gawande flatly states that “all doctors make terrible mistakes” (657). In doing so he explains certain failures and errors that doctors commit that led to situations that in danger patients. Gawande first mentions a study that found “…nearly
Woo, A., Ranji, U., & Salganicoff, A. (2008). Reducing medical errors with technology. Retrieved March, 2012, from http://kaiseredu.org
Milani, Oleck and Lavie reported that Medical errors are the eighth leading cause of death in the hospitals. About 44,000 to 98,000 people die each year from adverse effects from medication errors, 1 million annually die in
Furthermore, short staffing affects the quality direct care each patient receives. The National Coordinating Council for Medication Error Reporting and Prevention (2012) states an estimated 98,000 individuals die every year from medical errors in the United States. One out of many significant tasks nurses do within their scope of practice is medication administration. Research shows a relationship between short staffing on medication errors: the longer the hours nurses work, the higher the chances of medication errors (Garnett, 2008). (include definition of medication error) Administering medications requires knowledge of patient rights, pharmacological information on the drug, adverse effects, proper dosage calculations, and hospital protocols. When nurses are assigned more patients, they are pressured to give due medications on time. Sometimes due to hunger or fatigue, nurses give the wrong medication to the wrong patient (Frith, Anderson, Tseng, & Fong, 2012).
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
According to the Institute of Medicine (IOM) which has been on the forefront in undertaking research studies, pertaining to the prevalence of medical errors; systemic flaws are largely to be blamed for the high number of medical errors (BMJ Publishing Group Ltd 2011). The Hastings centre also shares the same sentiments when they state that “Many errors can be traced to flaws in complex systems of healthcare delivery, not flaws in individual performance” (The Hastings centre 2011, 5). These revelations come amid increased blame on healthcare workers for their apparent neglect of safe healthcare practices. IOM gives an example of poor communication between healthcare providers as one of the main problems associated with systemic flaws which consequently lead to medical errors. Because of this reason, the institute claims that focusing less on individuals and more on systems is likely to reduce the prevalence of medical errors.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
“When Doctors Make Mistakes” narrates an event where the author Atul Gawande, a doctor, made a mistake that cost a women her life. He relates that it is hard to talk about the mistakes that occurred with the patient's family lest it be brought up in court. In that instance the family and doctor are either wrong or right, there is no middle ground in a “black-and-white mortality case”(658). Even the most educated doctors make simple mistakes that hold immense consequences but can only speak about them with fellow doctors during a Morbidity and Mortality Conference.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).
The health care is extremely important to society because without health care it would not be possible for individuals to remain healthy. The health care administers care, treats, and diagnoses millions of individual’s everyday from newborn to fatal illness patients. The health care consists of hospitals, outpatient care, doctors, employees, and nurses. Within the health care there are always changes occurring because of advance technology and without advance technology the health care would not be as successful as it is today. Technology has played a big role in the health care and will continue in the coming years with new methods and procedures of diagnosis and treatment to help safe lives of the American people. However, with plenty of advance technology the health care still manages to make an excessive amount of medical errors. Health care organizations face many issues and these issues have a negative impact on the health care system. There are different ways medical errors can occur within the health care. Medical errors are mistakes that are made by health care providers with no intention of harming patients. These errors rang from communication error, surgical error, manufacture error, diagnostic error, and wrong medication error. There are hundreds of thousands of patients that die every year due to medical error. With medical errors on the rise it has caused the United States to be the third leading cause of death. (Allen.M, 2013) Throughout the United States there are many issues the he...