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opposition to medication error prevention
mitigating medication errors
opposition to medication error prevention
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Risk Management
Risk management is defined as a program directed toward identifying of, evaluating of, and taking corrective action against potential risks that could lead to injury of patients, staff, or visitors. It is a planned program of loss prevention and liability control, and its main purpose is to identify, analyze, and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents and injuries (Decker and Sullivan, 2001). Risk management is a continuous daily program of detection, education, and intervention. This paper will describe the risk management issues at Great River Medical Center as they pertain to medication errors, and will describe the methods that are currently taking place to address this issue.
Identifying Potential Risk
Identifying potential risks for accident, injury, or financial loss requires formal and informal communication that involves all organizational departments in the facility. The risk management department at Great River Medical Center conducted on study on medication errors in the facility during preparation for a JACHO inspection. During this study, they discovered that medication errors had increased steadily over a 2 year period, and that many of them were because of illegibility reasons. The two most common legibility reasons included reading the initial order and reading the medication on the hand written medication sheet.
According to Michael R. Cohen, MS, FASHP, from the Institute for Safe Medication Practices, poor handwriting is the leading cause of medication errors. Poor handwriting can blur the distinction between two medications that have similar names. And, many drug names sound similar, especially when spoken over the telephone, enunciated poorly, or mispronounced.
At Great River Medical Center, this was also found to be one of the leading causes of medication errors. The inability of the nurse to read the written order and the inability to read the written medication sheet accounted for 20 % of the medication errors at GRMC. Other reasons for medication errors at GRMC include the following:
Incomplete patient information (not knowing about patients' allergies other medicines they are taking, previous diagnoses, and lab results, for example);
Unavailable drug information (such as lack of up-to-date warnings);
Miscommunication of drug orders,...
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...ch new implementation process. With the use of the Omni Cell dispensers, computerized order entry, and the electronic medical record, the hospital has seen a reduction of errors and near misses at approximately 75%. Along with this great statistic, also comes peace of mind to an already stressed out and over worked staff, that wants to provide the best care possible for the patients.
References:
Anonymous, (2004). Nursing BC. Vol.36, Iss.5; pg.33, Vancover. Retrieved December 18, 2004 from www.proquest.com.
Business Wire, (2004). Hospitalist Physicians Partner with Clinical Pharmacists to Improve Patient Outcomes, Reduce Medication Errors. Business Wire, pg. 1, New York. Retrieved December 19, 2004 from www.proquest.com.
Davis, J.L. and Smith, M. (2002). Medication Errors Rampant in Hospitals. WebMD Medical News. Retrieved on December 20, 2004 from www.mywebmd.com.
Institute for Safe Medication Practices, (2004). Measuring Medication Safety, retrieved on December 19,2004 from www.ismp.org.
Stein, R. (2004). Automated Systems For Drugs Examined; Report: Computers Can Add to Errors. The Washington Post, pg. A03. Retrieved December 20, 2004 from www.proquest.com.
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
The most common kind of medication error is administering the wrong medication or giving wrong doses. A medication error is any error that happens to patients whether they suffer any harmful results or not. Inappropriate nurses-to-patients ratio should be taken into consideration because it can cause medication errors. A new study shows that every year about 210,000-400,000 people who were admitted to the hospital die due to medication error; it also shows that is is “the third leading cause of death behind heart disease and cancer”(MacDonald). For instance, an interview was done with Nurse Carol, a retired nurse; she said that she made a medication error while administering medication to one of her patients. She said that she was rushing and accidentally gave Cozaar to one of her patients instead of Colace. Cozaar is often used for high blood pressure and Colace is for constipation. She said her patient’s pressure dropped very low after taking the medication; she realized then that she gave the patient the wrong medication. Nurse Carol also said that if she did no...
In conclusion the study showed a decrease in reported medication errors by 20% (Truitt et al. (2016). The introduction of these systems has greatly changed the delivery of medication in hospitals. Medication administration errors in hospitals put the patient in danger and cause great harm, depending on the severity. It is so important that medication errors do not happen in the hospital. It may not be possible to eliminate all errors, but reducing the amount of errors would benefit
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
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.
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.
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.
Nurses are expected to provide a competent level of care that is indicative of their education, experience, skill, and ability to act on agency policies or procedures. In a study of 1,116 hospitals Bond, Raehl, and Franke (2001) found, “Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year”(p. 4). This means at least one medication error occurs every 24 hours in those facilities studied, and these are preventable errors. The main responsibilities of nurses when administering medications are to prevent or catch error, and report such error. Even if the physician or prescribing health care professional has made a mistake in the order, it is the nurse’s job to question the
The authors of Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit explored the effectiveness of computerized physician order entry (CPOE) systems on medication errors. The study’s stated purpose was “to see the impact of CPOE on the frequency of medication errors at the degree of physician ordering in a pediatric critical care unit (PCCU)” (Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R., 2004). The work was set in the PCCU of an academic foundation and included medication errors from the two month period before the implementation of CPOE – October 4, 2001 to December 4 2001 – and a two month period after CPOE – January 4, 2002 to March 4, 2002 – with a one month period in between when no information was garnered in order to acclimate hospital staff (Potts et al., 2004). Each error was categorized into one of three groups: potential adverse drug effects (ADEs), medication ordering errors (MPEs), and rule violations (RVs). The results
six percent of these medication errors occurred at the time of admission, time of discharge or
Tang, F.I., Sheu, S.J., Yu, S., Wei, I.L., & Chen, C.H. (2007). Nurses relate the contributing factors involved in medication errors. Journal of Clinical Nursing, 16(3), 447-457.Retrived form EBSCOhost.
- 29 studies found slips and lapses as common causes of error (Keers et al., 2013). Misidentification of medication or a patient are the most frequent and misreading a medication label/ product, prescription or other documentation are also common.
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.
This paper will explore some ways facilities are trying to improve on safe medication administration. Many new system safe safeguards are being implemented and reducing the amount of medication errors. Another area facilities are improving is with better medication reconciliation. This collaborated effort may seem lengthy in the beginning but it is a crucial factor in reducing many mistakes. Extra safety measures taken with new graduate nurses with medication administration also may play a key role in reducing errors. In conclusion of the paper I will discuss what I feel about how I prevent making medication errors. In addition, how I care for myself on days that I am not working. Having a clear