Analyzing Risk with Enterprise Risk Management Paper
University of Phoenix
Dr. Mary Jo Brinkman
June 29, 2015
MEDICATION ERROR INCIDENT REPORT
DESCRIPTION OF THE INCIDENT: Nurse was passing medication at a particular room in a given hospital in the state of California. There were about four patients in the room as was approved by the regulation. Nurse mistakenly gave medication to the wrong patient, while he was laying down on his bed without properly checking if it was actually the right resident. This is a hundred bedded hospitals with behavioral residents that are confused and have the tendency of …show more content…
According to Caroll & Brown (2011), medication errors occur in every health care setting, including the physician‘s office. It is estimated that there are two hundred and eighteen thounsand, medication- related deaths annually, with a total cost of approximately one hundred and seventy-seven million. Events related to medications are the third – leading cause of death in the United States after heart disease and cancer (Caroll & Brown, 2011). The first steps of prescribing and administration are where error is mostly the highest in hospitals. Medication errors can include the following: wrong dosage, wrong route, wrong frequency (of rate for IV), wrong medication wrong choice of medication for condition, wrong time, wrong administration technique, wrong patient missed dose, known drug interaction, known allergy to drug, wrong reason (Caroll & Nakuruma,2011). Ideally, the organization will introduce a reporting system strategy that is specific to the clinical area to focus on this vital risk management issue at hand (Caroll & Nakuruma, 2011).
Criteria 2: Customer risks
Description of the risk management process External and internal risk consequences from the incident Plans to monitor and opportunities
Management process involves:
1. Identify and prioritize strategically important risks.
2. A time frame within which incidents must be reported
3. Designation of the individual to receive
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When it comes to medication errors several things may occur such as adverse drug event, unexpected deterioration, and even death in severe cases. AHRQ (2015) states, “an adverse drug event (ADE) is defined as harm experienced by a patient as a result of exposure to a medication, and ADEs account for nearly 700,000 emergency department visits 100,000 hospitalizations each year.” There are many ways that errors may occur such as dispensary errors, prescription errors
In Australian hospitals medication administration errors make up 9% or 1 in10 of all medication administrations. These errors include wrong doses, wrong intravenous infusion rates and errors made by prescribing doctors. Errors on discharge of patients were increasingly higher with up to 2 errors per patient related to doctors transcribing discharge medications (Roughead, Semple, & Rosenfeld, 2016).
Medication errors are the leading cause of morbidity and preventable death in hospitals (Adams). In fact, approximately 1.5 million Americans are injured each year as a result of medication errors in hospitals (Foote). Not only are medication errors harmful to patients but medication errors are very expensive for hospitals. Medication errors cost America’s health care system 3.5 billion dollars per year (Foote).Errors in medication administration occurs when one of the five rights of medication administration is omitted. The five rights are: a) the right dose, b) the right medication, c) the right patient, d) the right route of administration, and e) the right time of delivery (Adams). Medication administration is an essential part of
Medication errors are focused on: terms and definitions; incidence of and harm; risk factors; avoidance; disclosure, legalities & consequences (Wittich, Burkle & Lanier, 2014). Medication errors categories have been developed by the American Society of Health-System Pharmacists (ASHP). Examples of these categories are based on prescribing, omitting drugs not administered, timing, unauthorized drug, wrong dosage, wrong preparation, expired drug, not using laboratory data to monitor toxicity (Wittich, Burkle & Lanier, 2014). Additionally, this article examines in depth common causes leading to medication errors, drug nomenclature, similar sounding drugs, unapproved abbreviations and handwriting, medical staff shortages and manufacturer medication shortages. Even though this article provides an informative overview for physicians, other allied health personnel may benefit too. This is valuable knowledge for the health care professional not just physicians in order to provide safe care for their
Errors made while administering medications is one of the most common health care errors reported. It is estimated that 7,000 hospitals deaths yearly are attributed to medication administration errors.
Medication errors in the hospital setting have significant potential to result in serious injury and even death, thus effecting patients, families, health care professionals, and hospitals. Approximately 400,000 adverse drug effects (ADE) occur each year (Institute of Medicine, 2006). Considering that not all medication errors are discovered and reported, this number is likely to be underestimated. These errors not only contribute to patient morbidity and mortality, but also cause increased length of stay and hospital expenses. It is estimated by the Institute of Medicine (IOM) that $3.5 billion is spent annually as a result of ADEs (IOM, 2006).
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
Research shows that medication error in hospitals and other health care settings leads to 373,000 preventable adverse drug events (ADEs) per year and that these events would increase to 478,000 within 20 years in the absence of additional preventive measures (Federal Register, 2004).
A major concern or challenge of ABC hospital is a recent incident of medication administration error in its emergency room (ER) which almost resulted in the death of a 55-year-old female patient. This is a case of medication administration through the wrong route. The Food and Drug Administration (FDA) defines a medication error 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. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding;
As a student pharmacist, I am interested in medication errors and initiatives for their prevention. In response to the IOM’s report, the Food and Drug Administration (FDA) agency enhanced its error reduction strategies by implementing a new division dedicated to medication errors.3
In 1999, the Institute of Medicine (IOM) “Too Err is Human” estimated 98,000 deaths yearly due to medical error. Many of the errors are the result of adverse drug events, most of which occur during the prescribing and administration stages of medication administration (Guo, Iribarren, Kapsandoy, Perri, and Staggers, 2011). These errors are a significant cause of morbidity and mortality in hospitalized patients. One report estimates that when all types of errors are accounted for, every hospitalized patient can expect on average one type of medication error per day and during 2006, adverse drug events resulted in approximately 400,000 cases of error at a cost of over $3.5 billion (pp. 202-224). Studies have demonstrated a
Medication error is defined as the following by the National Coordinating Council for Medication Error Reporting and Prevention: “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. 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” (Anthony, Wiencek, Bauer, Daly, & Anthony, 2010). Medication errors cause increased length of patient hospitalization and morbidity and mortality (Pape
Which according to the FDA Medication Error is the top cause of injuries and death in the United States? However back in 1999 the Institute of Medicine estimated 98,000 people died in the hospital yearly because of the medication error… Which these statistic tops the death rate linked to breast cancer, motor vehicle accidents and also acquired immunodeficiency syndrome. However, the cost of errors can reach up to the outstanding balance of 75 billion annually.
When implementing ways to eliminate medications errors are impossible, however best practices should be applied to avoid as many concerns or issues that could present itself. Through research there are many approaches that have been found to support the reduction of medication errors. The first areas to review was the way that medication orders are written, too many times medication orders are left to facilities with non-licensed nurses to transcribe orders or to receive a verbal order from the physician’s office, sometimes written prescription are also faxed. When orders are received the staff member should verify the order with the physician’s office or have the office to escript the prescription directly to the pharmacy. Therefore if the order is incorrect, then the pharmacist who is licensed can obtain the correct order for the facility, it then can be
Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error