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How to analyze the problem of medication errors
A study to assess the causes of medication error
How to analyze the problem of medication errors
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Prevention of medication errors within a hospital setting, is one of the many quality and safety issues that health facilities face very frequently. Avoiding medication errors is very important because these errors lengthen hospital stays, increase in-patient expenses, and can lead to several thousands of deaths annually in the United States. These errors also weakens the patients’ confidence within the physicians and the health care system. Medication errors are often caused by a sequence of system problems. Errors occur due to the lack of knowledge, standard fulfillment, or failures in the systems. Medication errors can be committed by both experienced and non-experienced staff.
According to British Pharmacological Society, “prevention of medication errors has therefore become a high priority worldwide. There is mounting evidence that systems that use information technology (IT), such as computerized physician order
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As a nurse, it is our job to help with the prevention of medication errors. By doing so, the nurse is able to provide safety and protection for their patients. Another way the nurse can help with prevention, is to check the patients’ charts and verify each medication administration before giving the medication. This illustrates the importance of advocating for patients in the nursing profession and how it is in our practice to make sure patients are receiving optimal medical treatment. Team work within multiple departments, including the pharmacy, medicine, nursing, risk management, and administration can also contribute to the prevention of medication errors. Medication errors are one of the most serious aspects interfere with the patient's safety in the hospital. By following the prevention strategies, the doctors, the pharmacist and the nurses can provide safe medication administration to the
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
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.
...estions if not 100% sure of something or use a double checking system. When a nurse is administrating medication, they should use the ten rights of medication administration (right patient, right drug, right route, right time, right dose, right documentation, right action, right form, right response, and right to refuse). Nurses should always keep good hand hygiene and always wear appropriate clothing to prevent from the spread of disease. Good communication with patients and healthcare team members is also key to success. Keeping on the eye on the patient within an appropriate time is important. If the patient ever seems to be looking different than their usual self vitals should be taken immediately. Encouraging patients to ask questions if they are unaware of something can prevent errors as well. Nurses should make sure the patient is on the same page as they are.
Baccalaureate nurses are responsible for providing and ensure our patients safety. The knowledge from others mistakes can help informs nurses of extra precautions that we can take to ensure our patient’s safety. Risk Analysis and Implication for practice course helped me understand the steps I as a nurse can take as well as the facilities I work for to help reduce the number of medication errors that occur. Interviewing the pharmacist help me get a better insight to what facilities already have in place to help prevent medication errors. However like most things you have to have educated and compassionate caring staff to enforce and follow the guidelines set in place.
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
Implementing technology in a clinical setting is not easy and cannot be successful without a well-organized system. It is important that healthcare providers understand the electronic medication administration record (eMAR) and its role in improving patient safety. One of the most significant aspects of healthcare is the safety of our patients. Medication errors account for 44,000-98,000 deaths per year, more deaths than those caused by highway accidents or breast cancer. Several health information technologies help to reduce the number of medication errors that occur. Once of these technologies is bar-code-assisted medication administration (BCMA). These systems are designed to ensure that the right drug is being administered via the right
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).
Agyemang, REO, and A While. "Medication errors: types, causes and impact on nursing practice." British Journal of Nursing (BJN) 19.6 (2010): 380-385. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
A newly employed critical care nurse was just about to finish a 12-hour night shift when she realized she had one more patient to administer medication to. It was the busiest Friday night shift she has ever worked due to a poor nurse-patient ratio, and the workload felt impossible. She gave her last patient the properly prescribed medication, but failed to notice that the physician hastily wrote an updated dosage for a high risk medication, Digoxin. The patient’s heart rate began to slow down and life-saving procedures had to be performed. Medication errors are “any preventable event that may cause, or lead, to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer (About Medication Errors, 2015)”.
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
For many patients the scariest part of being in the hospital is having to rely on other people to control their life changing decisions. There are multiple causes of patient harm, one of the major contributors are medication errors made by health care professional. Medication errors are inappropriate dispensing and administration of drugs which cause harmful effects such liver damage and excessive bleeding. Most cases of medication errors in hospitals occur as a result of wrong diagnosis by the doctors leading administration of inappropriate drug, poor communication between doctors and nurses and between patients and nurses who issue the drugs. However in an article by the International Journal of Nursing practice, in Australia many occurrences
The goal of any medication practice and dispension is to improve the quality of life of the patients while minimizing the medication risk to the patient. Patients are always subject to errors and risk during the medication period. Medication errors include among others prescription errors, dispensing errors, medication administration errors, omission of ordered drugs, timing, and even patient compliance errors (Goldspiel et al., 2015). Health care organizations are centers for care and rescue for patients suffering from different health issues. Therefore, it is the duty of the health care managers and providers to ensure that patients do not develop further health issues and complication due to the medical errors.
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?
Grissinger, M., & Globus, N. J. (2004). How technology affects your risk of medication errors.Nursing2004, 34(1), 36-41. Retrieved from www.nursingcenter.com