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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.
Nurses were the professional group who most often reported medication errors and older patients were those most often affected in the medication errors reports analyzed for this study (Friend, 2011). Medication error type’s revealed omitted medicine or dose, wrong dose, strength or frequency and wrong documentation were the most common problems at Site A where the traditional pen and paper methods of prescription were used; and wrong documentation and omission were the most common problems associated with medication errors at Site B where the electronic MMS was introduced (Friend, 2011). Reports of problems such as wrong drug, wrong dose, strength or frequency, quantity, wrong route, wrong drug and omitted dose were less frequent at Site B (Friend, 2011). The reduced incidence of omission errors at Site B supports suggestions that an advantage of the MMS is easy identification of patient requirements at each drug round time slot. Despite the finding of less omission errors at site B where the MMS had been introduced, there was a relatively high frequency in the incident reports of medication errors related to both omission and wrong dose, strength and frequency at both sites (Friend, 2011).
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
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
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.
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.
Safety is a primary concern in the health care environment, but there are still many preventable errors that occur. In fact, a study from ProPublica in 2013 found that between 210,000 and 440,000 patients each year suffer preventable harm in the hospital (Allen, 2013). Safety in the healthcare environment is not only keeping the patient safe, but also the employee. If a nurse does not follow procedure, they could bring harm to themselves, the patient, or both. Although it seems like such a simple topic with a simple solution, there are several components to what safety really entails. Health care professionals must always be cautious to prevent any mishaps to their patients, especially when using machines or lifting objects, as it has a higher
It is very disturbing at the number of errors that occur in children who receive medication in the ambulatory care setting. According to Medication Dosage Error...
Physicians ultimately decide what dose and drug will benefit the patient and restore them back to health. Held by the standards set by The College of Physicians and Surgeons, Physicians must abide by the Health Professions Act. Physicians are responsible to prescribe the right medication and right dosage. It is thought that physicians and other prescribers are ultimately to blame for medication errors. Although malpractices do occur among physicians, nurses are responsible to have a thorough understanding of the medications one administers to their patients. A nurse does not just simply do what they are told and administer drugs without having a thorough understanding and background knowledge. Nurses are to know the purpose of each drug they administer, the therapeutic effects, side effects which can be harmless or injurious, and adverse effects which is a severe negative response to the drug (2009). In reference to the previously mentioned scenario, the physician’s handwriting was careless and illegible. Although the Physician demonstrated lack of clarity, the nurse noticed the hastily written sentence signed by the physician and continued to administer the drug as she had routinely done the past couple days. Nurse’s should have a strong pharmaceutical knowledge background and be aware of the potential harm a medication could cause. In the process of medication administration, registered nurses are responsible to “determine that each medication order is clear, accurate, current and complete. Medications should be withheld when a medication order is incomplete, illegible, ambiguous or inappropriate; with concerns being clarified with the prescriber (CNO, 2015)”. The critical care nurse demonstrated ineffective communication, which was shown by failing to ask the physician for clarification. Another instance of miscommunication is during medication
Tzeng, H., Yin, C., & Schneider, T. E. (2013). Medication Error-Related Issues In Nursing Practice. MEDSURG Nursing, 22(1), 13-50.
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.
Pharmacists and technicians provide patients with safe and accurate medication in a timely manner. This is not a task for pharmacists or technicians alone; it is a task that requires both personnel in order to be accomplished.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
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...
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...
What classifies as a Medication errors? An error can occur any time during the medication administration process. A medication error can be explained 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 healthcare professional, patient, or consumer” (National Coordinating Council for Medication Error Reporting and Prevention, 2014, para 1). Rather it is at prescribing, transcribing, dispensing or at the time of administration all these areas are equally substantial in producing possible errors that could potentially harm the patient (Flynn, Liang...