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After reading two articles, one from American Association of Critical-Care Nurses (AACN) Bold Voices, talks about Sarah Roth experience as a registered nurse. It demonstrated how easily she became distracted trying to manage multiple patients that resulted in a drastic error by hanging the wrong intravenous bag. Sarah was trying to get the new client that arrived to her unit situated and across the hall, she had 23-year-old male patient that was critically injured from falling off a bridge which resulted in chest and lung injuries. He had completed another IV bag of cisatracurium besylate (Nimbex), which is a nondepolarizing skeletal muscle relaxant and she heard the pump beeping. The patient had called for help. She quickly left the new patient to go hang another IV bag for the 23-year-old without checking the medication or scanning it into the Medication Administration Record (MAR). However, Sarah marked the medication as being competed in the MAR as done prior to ending her shift. Sarah gave a bedside report to the oncoming nurse and left. The next morning, she received a call from her nurse manager reporting that …show more content…
For instance, in today’s world of increased technology most hospital facilities will have in place bar coding medication scanning systems. Utilizing this type of tool would have allowed them to verify the medication rights. Sarah had that opportunity, but she made a poor clinical decision to wait instead of scanning the medication immediately. Another cause of these errors in the articles, especially in Sarah’s case was not minimizing outside distractions when she was handling a patient’s medication. Sarah said, “I opted for speed and convenience over the safety of my patient” (Roth, 2016, p. 16). Nurses being distracted and not properly reading labels are a common cause for an error to
For my research paper, I will be discussing the impact of medication errors on vulnerable populations, specifically the elderly. Technology offers ways to reduce medication errors using electronic bar-coding medication administration (BCMA) systems. However, skilled nursing facilities (SNFs) are not using these systems. Medication is still administered with a paper or electronic medication administration record (eMAR), without barcode scanning. In contrast, every hospital I have been in: as a patient, nursing student, and nurse uses BCMA systems. The healthcare system is neglecting the elderly. Nursing homes should use BCMAs to reduce the incidents of medication errors.
The nurse, a traveling nurse, was working on a unit and received orders for infusion of normal saline in a 7 month old. He saw a small bag of what appeared to be saline on the desk in the nurse’s station, with the manufacturer’s pre-printed labeling indicating that it was filled with normal saline. One key aspect, as described by the traveling nurse, was that he had encountered in other health systems that pediatric infusions were specified in small bags. Based upon these two perceptions, the nurse administered the infusion – despite the pharmacy applied label being on the other side of the bag. Needless to say, the child died shortly after receiving the infusion, despite resuscitation attempts. The infusion was actually prepared for his adult patient
4). Examples of how nurses can integrate this competency include; using current practice guidelines and researching into hospital’s policies (Jurado, 2015). According to Sherwood & Zomorodi (2014) nurses should use current evidence based standards when providing care to patients. Nurse B violated one of the rights of medication administration. South Florida State Hospital does not use ID wristbands; instead they use a picture of the patient in the medication cup. Nurse B did not ask the patient to confirm his name in order to verify this information with the picture in the computer. By omitting this step in the process of medication administration, nurse B put the patient at risk of a medication error, which could have caused a negative patient
Wickens, Lee, Liu and Gordon-Becker (2014) defined human error as the “inappropriate human behavior that lowers levels of system effectiveness or safety”. Human error consists of mistake, which is the intended action that turned out to be inappropriate; slip, which is the unintended incorrect act; and lapse, the omission of nonintentional errors (Wickens, Lee, Liu & Gordon-Becker, 2014). There are various instances of human error demonstrated in the case description including, the nurse entering the MRI room with the oxygen tank (mistake), failure to check the level of oxygen in the tank (lapse) and the oxygen tank accidentally flying over to Michael’s head
From watching this video, I learn how most medical errors aren’t always simply due to the caregiver’s performance or practice, but instead can be accompanied by the flawed systems. In the twins’ case the error was made due to human error, but the fact Hep-lock and Heparin were in a similar colored bottle and labeled similarly made it more difficult to distinguish between the two. I also learned about different techniques and technologies health care workers are trying to use to prevent medical error by improving old processes and systems or creating new ones. Check a box, save a life is one of the newer interventions, it is essentially a check list for resident surgeons (if used each resident is estimated to save a life). The barcode technology is also something newer that can help save lives by doing a safety check of the five rights for medication.
Most undergraduate nursing students are not being properly educated on proper medication administration. Clinical instructors and registered nurses need to be updated on medication administration reporting, so students do not develop bad habits when they become registered nurses. Registered nurses must also continue their education on med error prevention to prevent future errors. Another significant problem with registered nurses was that they did not have positive attitudes when reporting an error. Once these negative attitudes were changed, more errors were reported (Harding & Petrick, 2008). The three main problems that cause medication errors...
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).
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
When an error occurs, the first step usually taken is to identify the individual that is responsible for the mistake. Frontline providers in health care, like nurses and doctors, are usually held accountable when a mistake occurs that affects patient safety and care. While this is the easiest step, it is not the most effective. "When human error is viewed as a cause rather than a consequence, it serves as a cloak for our ignorance. By serving as an end point rather than a starting point, it retards further understanding [1]." Factors outlined in Henriksen 's hierarchy, e.g. individual characteristics, the nature of the work, human-system interfaces, work environment, and management, need to be taken into account to identify the source of the
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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.
Administration of medication is a vital part of the clinical nursing practice however in turn has great potential in producing medication errors (Athanasakis 2012). It has been reported that over 7,000 deaths have occur per year related to medications errors within the US (Flynn, Liang, Dickson, Xie, & Suh, 2012). A patient in the hospital may be exposed to at least one error a day that could have been prevented (Flynn, Liang, Dickson, Xie, & Suh, 2012). Working in a professional nursing practice setting, the primary goal is the nurse and staff places the patient first and provides the upmost quality care with significance on safety. There are several different types of technology that can be used to improve the medication process and will aid staff in reaching a higher level of care involving patient safety. One tool that can and should be utilized in preventing medication errors is barcode technology. The purpose of this paper is to demonstrate how implementing technology can aid patient safety during the medication administration process.
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...
The nurse confirmed patient identification, asked subjective questions focusing on chief complaints, performed a focused assessment, obtained medication list, baseline vitals, and assessed the patient’s past medical history. She asked the patient questions such as previous hospitalization/surgery, metal implants, allergies, health history, sleep apnea, and alcohol/tobacco use. The nurse told the patient the doctor would be with her shortly. The nurse reported to the doctor regarding the patient and obtained orders for treatment from the doctor. The nurse then started an IV line and hung an IV solution bag of normal saline because the patient was experiencing abdominal pain. The nurse also administered pain medications and the patient was ready to be discharged. The nurse gave discharge instructions and made sure that the patient had a ride
Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of the nursing profession, taking up to forty percent of a nurse’s time in providing nursing care (Fowler). Consequently, nurses are commonly held accountable for medication errors. To improve the safety of a vital aspect of nursing care, bar code scanning was introduced to reduce errors in medication administration. Although bar code scanning has its advantageous aspects, there are also disadvantageous qualities.