We all have experienced whether personally or heard a story second hand from a loved one or a friend of prescription snafu. One evening I started feeling tired, through dinner the feeling of tiredness increased, by the time dinner was over and we were cleaning up I was struggling, the feeling of tiredness was overwhelming, my thinking was muddled and I had a hard time with moving my body. It wasn’t until I missed the sink while trying to place an unfinished glass of ice tea on it. Glass and liquid shattered on the floor, on the cabinets and on my feet, did I decide it was time to lie down. I woke up 16 hours later feeling groggy, when I went to the bathroom I saw the pain killers that I took the evening before, I picked up the bottle and …show more content…
Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use." (PSO). The CDC also recognizes that medication errors pose a threat to public health. The CDC estimates that “700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually, resulting in an estimated $3.5 billion in extra medical costs every year! At least 40% of the costs of ambulatory ADEs are thought to be preventable.” (PSO) Adverse drug events are a leading cause of mortality in the United States. 82% of American adults take at least one medication and 29% take five or more medications. Prevention of risk associated with of medication is to improving quality of health, maintaining life, and decreasing he cost of associated medical expenses. There are many entities within the healthcare environment, (government, providers, non-profit and oversight committees) working to reduce medication errors. One such government entity is the Patient Safety Organization and the …show more content…
A listing of possible medications that a patient maybe taking including drug name, dosage, frequency and route will be compared at each step in the coordination points. This medication reconciliation process is a federally recognized standard and its goal is to provide correct medications for the patients at each step in the transfer process. Utilize Pharmacist expertise – In a Connecticut study, Pharmacist worked with Medicaid patients to help manage the patient’s medications. “The pharmacists found 917 drug therapy problems, resolved almost 80% of them after 4 encounters, and saved an estimated $472 per patient on medical, hospital, and emergency department costs.” (Results) Accountable Care Organizations are using Pharmacists to help resolve the two most common drug therapy problems 1) additional drug therapy is required for prevention, efficiency or palliative care. 2) drugs need to be calibrated in order to achieve the intended therapy
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 evidenced based problem that was identified for this research assignment, was that nurses were causing multiple medication errors in a clinical and practice setting. According to the authors Wolf, Hicks, and Serembus (2006), 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. It is very important for experienced nurses and nursing professors to identify medication errors to prevent them from harming the patient. Some of the errors that were identified were not reported because registered nurses didn’t want their peers to think they were irresponsible (Unver, Tastan, & Akbayrak, 2012). Nurse shaming did not help increase positive outcomes of reporting errors among nursing students and registered nurses (Harding & Petrick, 2008). When medication errors were reported they were not being reported properly, and the consequences for improper reporting were not taken seriously.
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.
I learned a lot from this experience. As I mentioned earlier first time when I saw pharmacist doing medication reconciliation I felt it is difficult task to do and hence I started getting more information about medication reconciliation from my friends and pharmacist whenever I got a chance. I prepared myself before I expose myself in this area, which helped me to gain more confidence when I was performing medication reconciliation with standardized patient. I learnt how important is Pharmacist role in finding and solving medication related discrepancies. From this activity, I learnt that it is very important to communicate effectively with patients and other health care providers. If I am unable to communicate properly I will not be able to
A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient (NCCMERP 2014). The death rate for medication errors averages around 7,000 deaths per year. Lawsuits for medication errors were mainly made against registered nurses because nurses are the last people to check a medication before it is administered. 426 medication error related lawsuits were made against registered nurses. (RightDiagnosis 2014).
Wright, A., FebloWitz, J., Phansalkar, S., Liu, J., Wilcox, A., Keohane, C., … Bates, D. (2012). Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools. American Journal of Health-System Pharmacy, 69, 221-227.
The service of Medication Therapy Management (MTM) is designed to maximize collaboration among different healthcare providers such as pharmacists, physicians, nurses and other healthcare professionals to reach the safest and effective use of medications which improve the patient outcomes. According to Medicare Prescription Drug Improvement and Modernization Act of 2003, the main goal is to improve patient’s comprehension of appropriate medication use, increase the patient compliance to the medication regimen, and improve identifying the adverse drug events. MTM service model is built on five core elements focusing on complete assessment and evaluation of the patient’s medication therapy regimen through patient-centered care service and to optimize
The Institute of Medicine and its article titled Preventing Medication Errors highlights the dire need that the medical community has in trying to prevent adverse drug events (ADEs). The article listed different ways to attempt to reduce the number of ADEs, some methods including; more extensive provider-patient teamwork and communication, using improvements in technology and prescribing medications, improved labeling for medications, and policy recommendations.
In the years of 2007 to 20112 the U.S. Centers for Disease Control conducted a survey on prescription drug usage. They reported that 49% of the people in the U.S. had taken at least one prescription drug in the past months, and around 22% had taken more than one prescription drug in the same time period. This percentage of people was significantly larger than the same research data founded over a decade earlier. Prescription were made for many important medicinal reasons that span in severity like: prevention and care for chronic diseases to painkillers for chronic/temporary pain. Because the use of drugs has become so widespread and easily accessible, the dangers of taking drugs that can adverse effects other than the listed side effects has increased exponentially. These adverse effects largely have to do with the netics of the person consuming the drug.
CARE GIVER: Pharmacists must provide caring services of the highest quality, and must view their practice as integrated and continuous with those of the health care system and other health professionals. DECISION MAKER: The foundation of the pharmacist’s work must revolve around accurate decisions made or taken regarding appropriate, efficacious, safe, and cost-effective use of resources (e.g., personnel, medicines, chemicals, equipment, procedures, and practices). Pharmacists must also play a pivotal role in setting medicines policy both at the local and national levels. The pharmacist must thus, possess the ability to evaluate, synthesize data and information, and decide upon the most appropriate course of action.
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).
Accurate medication documentation is a critical step in safe care transitions. When a patient is admitted to the hospital, a member or members of the healthcare team must identify the patient’s current home medication regimen. This process is called medication reconciliation and should be done at every transition of care (Peinado, Silveira, Vargas, & Vicedo, 2016). Incomplete or inaccurate medication documentation can be harmful if a physician orders the wrong type of medication or if a chronic medication is omitted from the orders. These are examples of medication discrepancies.
Studies have documented clients can suffer harm from adverse medication events, which is a leading cause of hospitalization for older adults (Lancaster, Marek, Denison-Bub, & Stetzer, 2014). Factors that play into adverse drug events include transitions in the care setting, the age of the home care client and their caregivers, storage of medications, and assumptions by home care staff. Quality health organization such as AHRQ and The Joint Commission stress the importance of a comprehensive medication reconciliation process. The Joint Commission has implemented National Patient Safety Goals related to medication reconciliation with an increased focus on client education and the necessity to keep an updated list of medications readily
A couple of strategies include a custom alert to prevent medication-timing errors and reducing errors through discharge medication reconciliation by pharmacy services, and bar-code systems. By using the computerized prescriber order entry nurses are able to receive an electronic order from the physician. This system helps to vanish handwritten doctor orders that are illegible. In 2013, Virginia Mason took the computerized prescriber order entry system a step further. Virginia modified the system to implement a custom alert before signing any medication order that could possibly have an error. Her goal was to modify the system to make it impossible for medication-timing errors. Because of Virginia Mason, fifty percent of medication timing errors never reached the patient. When patient’s transition from one form of care to another, medication discrepancies become a high risk. Medication discrepancies are defined as unexplained differences among documented medications across different sites of care. (Pippins, 2008, pg. 1) Many medication discrepancies occur when the patient is being discharged from an acute care setting. Studies have shown that by including the pharmacist during the discharge process medication discrepancy numbers have decreased. During a study, pharmacists found 63 medication discrepancies out of 104 patients. They found patients 8