Errors3 In Nursing

In the UK, there are more than 1 billion scripts prescribed and dispensed every year (HSCIC, 2013). There are over 12,000 pharmacies in the UK, and approximately 1.6 million people visit a pharmacy every day (HSCIC, 2013). It is therefore natural to assume that between these 1 billion prescriptions, an error or mistake will be made. Current studies suggest that of all the dispensed medicines, there are approximately 0.01-3.32% errors made in community pharmacy and 0.02-2.7% in hospital pharmacy (James et all, 2009).

Reflect on a recent error or near-miss that resulted in compromised patient safety in your organization.

Balancing activity of medication botches relies upon epidemiological data, area of bungles, and changes in execution. Support of principles is the best quality level in recognizing troublesome prescription related events and, in future, automated watching will be the system for getting threatening events beforehand they happen. Specifying reveals arrangement bungles, can trigger notification, and backings the scattering of a culture of safe practice. Audit is a for the most part clear instrument for evaluating bona fide execution and in masterminding remedial exercises to diminish the peril of arrangement goofs.

This discrepancy may increase the risk of type I or type II errors that may have an impact on public health as well as may cause economic loss due to the estimated 24 hour delay in reporting results. A type I error is the incorrect rejection of a true null hypothesis or in other words, it leads one to believe that a supposed effect or relationship exists when, in fact, it doesn’t (Banerjee et al., 2009). An example of this in terms of water quality monitoring is prohibiting swimming unnecessarily or reporting a false positive result which may lead to economic loss at high bather density beaches. A type II error is the failure to reject a false null hypothesis or in other words, it leads one to believe that a supposed effect or relationship does not exist when, in fact, it does (Banerjee et al., 2009). An example of this in terms of water quality monitoring is allowing recreational swimming during elevated risk, or reporting a false positive result which may lead to an increased risk of recreational water-associated illnesses amongst bathers.

In a similar case, “ASHP Guidelines on Preventing Medication Errors in Hospitals,” was experienced prescribing error incorrect drug or instructions for use of a drug product ordered or authorized by physician; illegible prescriptions or medication orders that lead to errors that reach the patient (1993). Another problem that might occur at the doctor’s office the doctor might misunderstands the patients concerns or symptoms and misdiagnose the patient. Sometimes accidents might occur and the patient might not get well and goes back to see the doctor and the doctor to correct their mistake. When mistake takes place there should be a monitoring and managing action plan should be put in place. An appropriate and correct statistical thinking required to apply the statistician’s finding for improving the prescription process by the pharmacist in this process is lacking and that is the root problem for the prescription issue in this process. Another problem that ties in with this problem is the doctor handwriting; the person that enters the prescription may not understand what it says. They assumes it says something totally different written and that is another reason why it is important for the verification of the prescription with the doctor. The problem is a common-cause variation as the right statistical thinking is the inherent requirement of the prescription process (Horel & Snee,

Mistakes and errors can occur normally in our clinical decisions in our clinical settings. In physical therapy settings, these errors could be resulted from such unintended factors such as insufficient experience in achieving some tasks and lack of cognitive and manual skills. The literature showed that the medical errors were not mainly occurred by the inadequate scientific knowledge where they are mostly cognitive in nature, and self-awareness is a way to prevent these errors (Nendaz & Perrier, 2012). The medical errors can be reduced and patient’s safety can be ensured if the physical therapists set some attainable goals that assist in decreasing the medical errors starting from self-awareness about these errors.

Chapter five discusses computerized provider order entry (CPOE). CPOE systems allow health care organizations access to tools that enhance the efficiency and delivery of patient care. While CPOE technology has proved beneficial, it is not deprived of challenges. The article that I selected to review, “Hospitals’ Computerized Systems Proven to Prevent Medication Errors, but More is Needed to Protect Patients from Harm or Death” (TheLeapfrogGroup, 2016) discusses how medication errors still occur despite the implementation of this technology.

According to Hospital Safety Scores (2014), as many as 440,000 people die every year from medical errors in hospitals. Not to mention the estimated tens of thousands that also die from missed diagnoses or side effects of medications. While there are a number of errors that can occur in a health care setting, medical administration errors are both the most detrimental and the most publicly seen errors that health professionals make. The study of nursing informatics is aimed at identifying process deficiencies and using technology to improve both communication and outcomes for the patient.

Simple medication errors can place patients at high risk for injury or even death. Doctors and nurses factor primarily as the main contributors in causing these errors. Prevention may be the key to decreasing medication errors through the use of a few simple steps. For example, doctors clarification of medications with the patient or family members, the writing of orders or prescriptions accurately and legibly, and nursing applying the five rights rule, right patient, right medication, right dose, right route, and right time. Additionally, the result of current statistical data has also proven the need to prevent medication errors in hospital setting. Some hospitals have utilized ways of preventing medication errors by using new technologies, one called the Pixus machine, a computerized system for dispensing drugs, another is a new bar code system that scans patient arm bands and nurses name badges. Unfortunately, system medication errors still occur because technicians have to fill those machines with medications. The technician can easily misread the dosage label and place them in wrong drawer. Through the rate of errors has decreased since these practices have been put in place in various hospitals, increased precautions should still be in place to insure patient safety.( Taylor Book, p736)

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

So how does this align with the current National Safety and Quality Health Service Standards? It comes under standard 4, medication safety, which describes the systems and strategies to ensure clinicians safely prescribe, dispense and administer appropriate medications to informed patients (Australian Commission on Safety and Quality in Healthcare, 2012, p. 3). Medicines are the most common treatment used in health care. Because of this commonality, medicines are connected with higher incidence of errors and adverse events when compared to other healthcare interventions. Some of these events are costly and potentially avoidable. Many solutions to prevent medication errors are found in standardisation and systemisation of processes. A recognised

The authors discuss the advantages of Computerized Physician Order Entry (CPOE) as a major enhancement in the improvement of patients’ safety. The authors point out that the program alerts providers of patients’ allergies and possible interactions at the same time when medications are prescribed. In the articles, the authors mention about two large studies sponsored by the Institute of Medicine (IOM) and the Leapfrog Group (LG) on CPOE, which was conducted in Colorado, Utah, and New York, had shown decreased results in adverse events in mediation errors when applying CPOE compared to the old methods of hand written prescriptions. Researchers firmly suggest that hospitals should initiate plans to integrate CPOE into their system. The authors also describe other studies sponsored by IOM and the LG about the effectiveness of adding CPOE to medical and surgical units, which showed significant reduction in medication errors of 55% and adverse drug events (ADEs) of 84%. Another

When a nurse is given a higher workload, nursing errors are likely to occur. The rate for nosocomial infections such as pneumonia, (MRSA), catheter-associated urinary tract infections (CAUTI), and decubitus ulcers increases (Sapatkin, 2012). A nurse on a busy schedule tends to not follow proper personal protective equipment (PPE) guidelines, acquire higher chances of needle stick injury, forget to wash or sanitize hands, and not double check their work (Cimiotti, 2012). In addition, a busy nurse may be at risk for possible pharmacological error (Sochalski, 2004). A nurse may accidentally mix up her patients due to the high workload. The more patients per nurse, increases the risk of harm significantly (Robb,

Factors associated with medication errors such as interrupted nurses, look-alike medication, wrong dosage given, wrong computation, nurses are multitasking or misleading hand written instructions (Jones, 2009, p. 41-46) can be prevented by the

The first feature that can be added to such a computer system to prevent this issue from occurring is to make it so that each time medicine is prescribed for a patient, doctors have to log in possibly by utilizing the new OneID technology (Skelton, 2012). This way, doctors will readily identify themselves before they prescribe medication, virtually assuring patients that they will not get the medicine that a previous doctor prescribed to someone else. It is possible to change settings for password requirements (Mitchell, no date) Although this system may become tedious for doctors who are attempting to prescribe more than one medication for a particular patient, it will certainly correct the greater wrong of patients getting incorrect medicine.