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b. Identify any potential issues in the system in which a mistake could be made.
c. What strategies could a RN use to prevent such drug errors? (20 points)
When the patient is admitted to acute rehabilitation and physical therapy, the patient will arrives with a packet with transport service that contains a typed med reconciliation from their discharging location. The nurse may manually enter (typing each drug name, each dose, route, times and special instructions) all these drugs as “home meds” into MEDITECH system. This may cause confusion as the drugs may not necessarily be the home meds the patient was taking at home before their hospital admittance, just their newly prescribed hospital drugs. The nurse will ask the patient (if they are alert and oriented, or else a family member if available at bedside) if they recognize the drugs and know their indications. If the patient is from a HCA hospital (which is common,) the drugs will already be in their electronic record and the admitting nurse will review last time administered for each drug before calling the doctor to review, edit or continue the current drugs for the patient. The doctor here has the opportunity to change route, dose, timing, or give additional drugs here. Pharmacy then is to check for interactions and appropriate med times (like cholesterol meds in evening). Some drugs (usually the very expensive or rare) are not stocked by pharmacy and so it is a drug that is continued under an order labeled “okay for patient to take own drug”, which means the patient’s family can bring in the unavailable drug and nursing brings it to be reviewed and barcoded by pharmacy, or else the drug is discontinued. After all is said and done, pharmacy reviews the drug list and then uploads all drug entries linked electronically to computer EMAR and the OMNICELL machine. After 5 pm, the nursing supervisor may have to track down the drug due to pharmacy not being in house. If they are unsuccessful to find it within the building, the patient may miss a dose that night, unless it is considered to be an emergent need, in which the drug can be transported over from main campus hospital by transport service. All admits after 5 pm are managed by the pharmacy at main campus hospital, who are easily accessed by phone.
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b. There are many possibilities for mistakes in this process used, which is why it is necessary for a second nurse to double check drugs. One probable place for error is keystroke slips behind the admissions nurse, especially when the patient is from a hospital that is not affiliated with HCA, which requires manual entry on the nurse’s part. On the physician side, the patient’s discharge drug reconciliation is not correct because a physician or resident who was not well known to the patient filled out the discharge drug orders to speed up the discharge process, and the drugs that have not been taken for days, weeks, or months, are continued again for the patient, along with all their new, current inpatient drugs. A way to verify this is to call the physician or resident and ask to verify the orders. This is an occurrence seen with patients who have been in the inpatient setting for weeks to months, usually for a new diagnosis such as stroke. Another error is that typical times for drugs may not be followed, that is giving warfarin at 6 pm or cholesterol med at night, or checking digoxin daily orders so that it doesn't react with other blood-pressure drugs. Pharmacy usually catches these errors but sometimes it falls to the nurse to know that some drugs can only be given at some times in the day for maximum benefit as they are the last hands before the patient receives the drugs.
The OMICELL (drug dispensary) at my work is either located in a private or semi-private space. Sometimes during drug pull, a nurse may be interrupted. The nurse has the option to answer others that they will address any issues as soon as they're done pulling these drugs for that patient. Sometimes drugs may not be in the correct drawer (whether by pharmacy or nursing, there are no lids on these drawers which leaves room for human error) or the incorrect dose may be found with other doses of the same drug. A second chance for possibility of making a mistake is when the nurses scanning the patient and scanning the meds if they're interrupted either by family or aides or phone calls. The nurse may forget to half a pill, dilute a drug properly, or draw up the proper dose of drug. For this reason whenever I have a vial in front of me, I ask for a quiet zone from other staff and the patient in order to ensure that I will draw and administer the correct dose. For pills, I automatically draw a bold line through the middle of the paper side of the pill packet to remind me when I put drugs into the cup which is to be halved.
C. Errors can come from anywhere where a process goes through many hands. In my opinion, less manual typing for the already overloaded nurse could relieve a lot of stress by the use of universal EMAR systems that are utilized hospital to hospital, regardless of the company. Physicians should review all their resident’s work, and review patient’s former home drugs and know how a patients home drugs and inpatient drugs could have interactions with each other. Nurses should always double check each other. Before giving a new patient any drugs, the nurse should check the paper MAR against the admissions EMAR. Pharmacy should work diligently to ensure drugs are always in the right pockets of the OMNICELL and ensure drugs are scheduled for proper times as protocol. The nurse can notify them of errors. During med administration the nurse can use tools such as pill packet marking, silence, double checking all vials, and going over each drug with the patient before administration to ensure safety. The nurse should always call pharmacy if they are not sure about a drug or a dose of drug being given, or to question a scheduled time or proper route of a drug.
A. Discuss the impact of food on drug absorption, metabolism, drug toxicity, drug action, and timing of drug administration with respect to meals.
B. Using an actual patient analyze this patient’s complete drug regimen and state how food (meals/snacks) could impact the drug absorption, metabolism or action. Identify this patient by age, admitting diagnosis and concurrent diagnoses. Do not use insulin as an example. (30 points)
Food can interact with the effectiveness of drugs in many different ways. Food changes the drug absorption rate into the circulation. Food can also increase or decrease the total amount of the drug absorbed. Therefore, food changes the time of drugs’ feedback in the body and the total amount of drug delivered. Various types of food can have different interactions on drug. A high fat meal may intensify the absorption of some medications, while considerably decreasing others. The temperature of food and drink can also have a variable effect on drug. Hot liquids, like coffee and tea, may dissolve the release process of some timed-release medications. This may produce higher than wanted blood levels soon after the drug is taken. Also, increased volume of water improves the dispersing tablets in the gut. This usually keeps a drug from retaining in the GI tract for too long and causing stomach lining irritation. Fiber taken with any drug or supplement frequently slows movement of the medication in the gut. The delay in transport may decrease the drug dissolution and amount absorbed into the blood. This would reduce the drug’s effect. It is best to take any medication or supplement one hour before or two hours after having fiber. Calcium and like minerals found in food and supplements (i.e. antacids) can chemically bind to the drug and reduce absorption from the GI tract into the blood. This interaction is avoidable by time spacing doses. For instance, thyroid medication should not be taken with calcium due to its binding properties. To summarize, the oral route of administration presents many challenges to patients in foreseeing the outcome of their drugs. Patients should consults their pharmacist to look their drug list, lifestyle, medical condition and then predict what is best for the patient, optimally the easiest regimen to follow.
Explain why the liver is such a critical organ in drug metabolism. Be thorough in your answer as to the function of the liver. (20 points)
After a medicine has done its work and has been through circulation, the drug is metabolized. Metabolism contains two steps that take place mostly in the liver. Everything that enters into circulation (orally, injected, inhaled, through the skin, or created by the body) is passed to the liver, where they are manipulated, broken down, and converted. The transformations that happen in the liver are made possible by the working proteins of the body, enzymes. Each enzyme has a special job. Some breakdown molecules, while others bond small molecules into chains (“Medicines by Design”, 2007). The term first-pass effect refers to the speedy inactivation of some oral drugs as they process through the liver following absorption (Lehne). Many byproducts of drug breakdown by enzymes, called metabolites, are not as chemically active as the original molecule. Consequently, the liver is called a "detoxifying" organ. Sometimes the resulting drug metabolites may produce chemical doings of their own—occasionally as strong as that of the original drug. Doctors must account for these added properties when prescribing drugs to patients.
1. Discuss bioavailability. Explain why differences in bioavailability are of great concern for drugs with a narrow therapeutic index. (20 points)
Bioavailability is the drug’s capability to join the body’s circulation from its site of origin. Differences in bioavailability are of greatest concern with drugs that have a narrow therapeutic range because a seemingly small change in drug level can make a significant change in response. A small decline in drug level may cause ineffective drug, and small increase may cause toxicity. With these differences in bioavailability can have significant impact. Other causes of variable absorption include alterations in the gastric pH, diarrhea, constipation, and food in the stomach. (lehne) drugs that are given orally are subject to the “first-pass” effect. The drugs are absorbed through the intestinal wall into the portal circulation. The liver then breaks them down before they are released into the blood stream. This is why, for many drugs, oral doses are higher than if you give the drug IV. IV drugs enter immediately into the blood stream.
National Institute of General Medical Sciences. (2007). Medicines by design (NIH Publication No. 263-MD-205019 and 263-MD-212730.). Washington, DC: U.S. Government Printing Office.
Lehne, R. A. (2012). Pharmacology for nursing care. St. Louis, Mo: Saunders.