Statistics show that between 1979 and 2006, there were more than sixty two million deaths investigated and of those, 244,388 were caused by a hospital medication error (Cox, 2010). The following information highlights medication errors made in three facilities in the United States with the drug Heparin. The focus of this paper will be on how the medication errors were made, what could have prevented them, the legal ramifications from the mistakes, and changes that were implemented to eliminate potential future risks. In September 2006, at Clarian’s Methodist Hospital in Indianapolis, six infants in the Neonatal Intensive Care Unit (NICU) were accidentally given excessive doses of heparin, resulting in the death of three of the infants (Thew, 2006). This day started out just like any other day in the newborn intensive care unit at Methodist. The nurse went to the medication cabinet to dispense Heparin, a blood thinner, for a handful of premature babies. This was a normal routine for the nurses in the NICU. Reports indicated that a pharmacy technician stocked the wrong vial dose of heparin in the NICU medication storage cabinet. The correct dosage of heparin for the use in flushing intravenous catheters is 10 units per mL, but unfortunately the technician stocked the 10,000 units per mL vials. Both vials are quite small and resemble a similar color of blue (Simpson, 2008, p. 135). The heparin vials responsible for the tragic events at Methodist Hospital were manufactured by Baxter Healthcare Corporation. In February 2007, Baxter “issued an Important Medication Safety Alert warning to healthcare providers that the look-alike features of the two vials with vastly different doses presented a risk of life threatening medication errors... ... middle of paper ... ... over babies’ hospital drug mishap. (2009, June 19). KTLA. Retrieved from http://www.ktla.com Simpson, K. R. (2008, March/April). Perinatal patient safety: Medication safety with heparin. The American Journal of Maternal Child Nursing, 33(2), 135. Retrieved from http://www.nursingcenter.com Thew, J. (2006, December 11). All things considered – Clarian examines its healthcare delivery system. Retrieved July 24, 2011, from http://nurse.com Vonfremd, M., & Ibanga, I. (2008, July 10). Officials investigate infants’ heparin OD at Texas hospital. ABC News. Retrieved from http://abcnews.go.com Waknine, Y. (2007, February 9). Heparin product similarities linked to fatal medication errors. Medscape News. Retrieved from http://www.medscape.com We’ll sue. (2008, March/April). Neonatal Intensive Care, 21(2), 10. Retrieved from http://www.nicmag.ca/pdf/NIC-21-2-MA08-web.pdf
Woodrum, D.(1998). Practice standards for administration of Exogenous Surfactant. (Survanta). University of Washington Academic Medical Center. Available: Http://neonatal.peds.washington.edu/NICU-WEB/surf.stm Accessed: 2/08/01.
...rofiles of Health Care Systems, The Commonwealth Fund, June 2010. Retrieved April 20th, 2011 from website: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1417_Squires_Intl_Profiles_622.pdf
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
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
Willis, E, Reynolds, L & Keleher, H 2012, Understanding the australian health care system, Mosby Elesvier, Chatswood, NSW.
Precision of a patient’s intravenous medication is essential; it must be safe from. contamination, toxicity, and side effects. Most people believe these medications are compounded or mixed by a trained and licensed individual. However, this is inaccurate because the pharmacy technician actually compounds a large percentage of a patient’s medications. Compounding involves a technician’s math skills, aseptic technique, and professional ethics.... ...
Some authors have pointed out that half of the medication errors may be generated in processes associated with changes in health care level,22,24,27 particularly where there is no routine practice of medication reconciliation. In studies where initial medication histories were compared with reconciled histories, a high proportion of errors with medication histories at admission were observed where medication reconciliation was not undertaken,22,23,26 reinforcing admission as a critical point of care. A systematic review of studies of medication discrepancies on hospital admission indicated that 60%–67% of prescription medication histories contained at least one error, either the omission of a medication being taken by the patient or the reporting of a medication not being taken. An estimated 11%–59% of these errors were deemed clinically significant.4 However, there is considerable variation in defining medication history errors at admission. Although unintentional omission of a medication is the most common form of discrepancy, few studies have included only omission errors, 28,29 most studies evaluating the prevalence of medication
while transferring patients between units. [After reviewing these events], “The Joint Commission identified “Improve the Safety of Using Medications” as one of the 2009 National Patient Safety Goals (Cleveland Clinic, 2009, p.1). In relation to this safety goal, hospitals created a medication reconciliation form that resides in the patient’s ch...
Despite the efforts to provide the best care, there are still different factors that may contribute to medication errors and they are the major cause of morbidity and mortality in the hospital setting. For instance, health care professionals, particularly nurses, use a broad variety of devices to help administer medications: infusion pumps, IV administration sets, oral syringes, etc. Infusion pumps are a common type of error identified in the hospitals and can cause serious harm, including death. Most of the errors are associated with
The team comprised of five registered nurses, five pharmacists, and two physicians. This team found and classified the errors based on seriousness. The observation was done by two independent individuals with a background in nursing. The observers followed the registered nurses as they administered medications to one hundred twenty two patients. The medication lists and the pharmacist dispensed medications were compared by the observers before the registered nurse began administering the medications. The observers also collected information about the experience of the registered nurse, the patient-nurse ratios, if the nurse double shaded medications, and/or if the nurse asked for help from other workers. The route, timing, rate, and handling of the medications were recorded. If a nurse appeared nervous, sick, or tired it was noted on the observation form. All distractions such as phone calls, noise, and interruptions were noted. The observations made were compared with the electronic medication list for the patient to check the route, dose, and timing matched up. All the data was reviewed by the professional team and the errors were classified by severity ranging from no harm to death. (Härkänen, Ahonen, Kervinen, Turunen, & Vehviläinen-Julkunen,
Safety is the main concern in Health Care. Medication error is another aspect. It can be a preventable one. According to the National Coordinating Council for Medication error reporting and Prevention who states “A medication error is 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” (2018). The purpose of this paper is to show how different organizations identify, analyze different types of medication error, use evidence
Medication errors are costly, not only to the healthcare facilities, but also the patients and families as well. For this reason, it has become of great importance for healthcare facilities to prevent these errors. It is estimated that approximately $3.5 billion is spent on drug related injuries occurring in hospitals alone (MedLaw, 2006). This price includes not only the cost of treatment after the fact, but also the cos t of the incorrect medication used for administration. Regarding the costliness to patients and their families, patient injury or death may occur as a result of a medication error. This may be due to an incorrect drug or perhaps an incorrect dose being administered. The possibility of the patient having an allergy to this incorrect drug administration could also further cause damage as well.
If medical professionals do not know what mistakes they are making, or how to fix them, the mistakes will continue. Nurses need to be aware of harmful medications and adverse effects that some medications have so that patients do not suffer from easily preventable side effects. There are many medications that look alike and sound alike so being conscious and knowing which medications cause confusion can reduce the chances of giving a patient the wrong medication. It is important to make sure the right patient is getting the right dose of the right medication, through the right route at the right time. If the above precautions are not followed precisely the patient could suffer from adverse effects and possible death. Not only is it important for healthcare providers to be educated on the safety of administering medications; patients too need to know the proper ways to administer medications once they are discharged from the hospital. It is important to note that education extends far beyond the classroom. Education can be as simple as informing another nurse of a common mistake they are unknowingly
Medication errors are an unfortunate occurrence in medical settings all throughout the world. Despite the best efforts of both nurses and physicians, medication errors occur on a daily basis. A medication error is not simply giving the wrong medication, it may consist of giving a drug via the wrong route, at the wrong time, or at the wrong dose. Statistics reported often vary, however the Food and Drug Administration reports that at least seven thousand people die annually as the result of medication errors. Every patient is at risk for being the victim of at least one medication error (“Strategies,” n.d.).
Chambers, C. D., Polifka, J. E., & Friedman, J. M. (2008). Drug safety in pregnant women and their babies: ignorance not bliss. Clinical Pharmacology & Therapeutics, 83(1), 181-183.