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
In the case study identify the incident and explain the problem that might trigger a root cause analysis. In this case study, a patient admitted to the intensive care unit (ICU) with septic shock requiring vasopressors that suffered an MI in the course of his treatment due to vasopressin overdose as the incident. The problem that triggered a root cause analysis was likely related to a log increase in the dose of vasopressin because of a prescribing error, pharmacy issues also figured prominently in this error, the computerized physician order entry (CPOE) system that did not eliminate medication errors and domino effect to the nurse that started the medication that eventually caused the patient to have an MI. The patient in this case was receiving the medication vasopressin, at a dose of 0.4 units/min, a dosage used for gastrointestinal hemorrhage and variceal bleeding rather than the correct dose of 0.04 units/min for treating shock. The vasopressin order was incorrectly written by a resident physician after he received a verbal order from his supervising critical care fellow (Flanders, S. & Saint, S., 2005). The dose that was used for the patient was so high that it acted as a vasoconstrictive agent to reduce the blood flow and facilitate hemostatic plug formation in the bleeding vessel thus causing the MI (complication of high dose vasopresson infusion) (Cagir, B. & Katz, J.). Furthermore, the nurse caring for this patient administered the incorrect dose of vasopressin as a result of the domino effect. In fact, the incorrect dose was given for more than 16 hours, which means that more than one nurse was involved in the error. It was not until a nurse was discussing the medication dosing with nursing students that the incorrect ...
The innovation of surfactant replacement therapy in the treatment of respiratory distress syndrome has proven to increase the survival and minimize the complications of the premature neonate. Replacing surfactant has lessened time on ventilators, and allowing the neonate and parents an opportunity to grow together earlier outside of intensive care. This paper will discuss the etiology of respiratory distress syndrome type I, the treatment options and nursing care of the neonate during surfactant replacement.
Overall, I retain three goals for this clinical day: Safely and efficently administer medication, enhance my nursing/CNA skills, and determine how to implement infection control into a health care setting. This week reflects my assigned time to administer medication in a health care setting for the first time, with a resident who retains nearly twenty medications. I except this experience will be a great learning experience, but it will also subsist slightly stressful. With the assistance of my FOR, my goal is to administer all of my resident 's medications without complications. To ensure that medication safety, I will perform the six medication rights and three checks prior to administration. Along with medication administration, a goal
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
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...
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
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
Medication errors are amongst the most common mistakes that have an impact on patient care. Medications are an absolute benefit if health care providers prescribe, dispense, and administer them to the patient by applying the appropriate technique. The administration of medication is a fundamental aspect of the nursing role and it is associated with significant risk, however, despite the health care team’s knowledge and devotion to quality care, errors with medications may occur. Therefore, it is important that health care providers are familiar with the most common encountered errors. Health care providers should be familiar with the basic rights of medication administration: Right drug, Right dose, Right patient, Right route, Right time, Right reason, and Right documentation and the three checks.
Medication Errors one of the biggest issues happening in an acute care setting today . Although, Medications are given based on the five rights principles: the right patient, right medication, right route, right dose, and right time. Even with the five rights principles medication errors are still happening. However, some of the errors that are occurring are due to poor order transcriptions and documentation, drug interactions, proper drug name and not paying enough attention and environment factors.
Patient safety must be the first priority in the health care system, and it is widely accepta-ble that unnecessary harm to a patient must be controlled.Two million babies and mother die due to preventable medical errors annually worldwide due to pregnancy related complications and there is worldwide increase in nosocomial infections, which is almost equal to 5-10% of total admissions occurring in the hospitals. (WHO Patient Safety Research, 2009). Total 1.4 million patients are victims of hospital-acquired infection. (WHO Patient Safety Research, 2009). Unsafe infection practice leads to 1.3 million death word wide and loss of 26 millions of life while ad-verse drug events are increasing in health care and 10% of total admitted patients are facing ad-verse drug events. (WHO Patient Safety Re...
Medication administration is a very important part of a registered nurses’ job. Multiple medications, patient issues, and technology all contribute to the complexity of medication administration. 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 health care professional, patient, or consumer’. In addition an error can also be the wrong drug, route, dose, preparation, time, technique, or documentation. Errors can be a serious problem for patients’ health. (Härkänen, Ahonen, Kervinen, Turunen, & Vehviläinen-Julkunen, 2015)
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.
“Medication errors were once the eighth leading cause of death in the United States” (Keane, 2014). With 44,000 to 98,000 annual deaths it is apparent that medication errors are still prevalent in healthcare settings. In a review done by Agyemang and While, a medication error is defined as a “failure to the drug treatment process that leads to or has the potential to lead to harm to the patient” (Agyemang & While, 2010). Medication errors are common, however, with proper education and training they can be prevented. A variety of factors can lead to medication errors including: interruptions while administering medications, misidentification of resident, poor communication between medical professionals, and general hospital chaos (Nazarko,
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.).