Work Place Distractions Lead to Deadly Outcomes Effective Ways to Reduce Medication Errors in the Health Care Setting Lincoln University Suzanne Norman-Ybarra One of the greatest fears of any nurse is harming or killing a patient by making a critical medication error. The U.S. Food and Drug Administration reports that a person dies accidently every day from a medication error and approximately 1.3 million sustain an injury from medication errors (U.S. Food and Drug Administration, 2016). Medication errors can result from the initial prescribing of the order, transcribing the order, entering the order, dispensing the medication, repackaging the medication with improper labeling, administering the medication incorrectly, …show more content…
In an effort to reduce the occurrence of medication errors, JHACO has thoroughly investigated and implemented new safety standards of care. JHACO implemented a new standard referred to as the “10 Rights of Drug Administration.” 1. The Right Drug, 2. Right Patient, 3. Right Dose, 4. Right Route, 5. Right Time and Frequency, 6. Right Documentation, 7. Right History and Assessment, 8. Drug approach and Right to Refuse, 9. Right Drug to Drug Interaction and Evaluation, and 10. Right Education and Information. Failure to follow the 10 Rights of Medication Administration can result in a patient’s injury or death (Potter, Perry, Hall, & Stockert, 2013). Further research in safety has proven that reviewing the physicians order three times significantly reduced transcribing errors or entering the order incorrectly into the electronic medical record. Training new nurses and experienced nurses to review every order three times has shown beneficial in patient safety and has reduced medication errors. Nurses and medical staff involved in medication administration are encouraged to have a buddy system, where there are two nurses or trained staff members who double check all medication calculations and assist with verifying high risk medication dosages. When there is a discrepancy concerning any medication administration, a Stop, Think and Call policy is implemented and the medication is held until proper documentation and verification have been obtained.
The standards, during this case, are referred to as the rights of medication administration and over the years there are 5, then six and currently in several places eight rights. All medication errors may be connected, in a way, to AN inconsistency in adhering to those rights of medication administration. The rights are educated in nursing education and coaching, as well as they are enforced by the nursing board and the employer.
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 dispensing errors, prescription errors , administration errors, and failure to monitor patient’s progress to name a
Patient safety is of high importance in the healthcare field. Medication errors are still of great concern in the healthcare setting. These errors are only one of many safety concerns. Medication errors occur often enough to be problematic, causing researchers to try to find the problem and come up with a solution. This error is a massive problem when a big part of nursing is delivering medications to patients. A health facility is thought to be a safe environment, when incidents like medication errors
Medication errors are one of the leading causes within a patient care setting thatcan jeopardize the client’s safety, and can even potentially be fatal. The six patient rights,right dose, time, route, medication, patient and documentation, all help prevent errors andpromote patient safety. The nurse needs to check off each patient right in order tosuccessfully pass medications. One of the leading causes for missing one of these patientrights is interruptions in the process of medication administration prep, or when activelygiving the medication to the patient. This paper will discuss why interruptions duringmedication administration can cause errors, and interventions the nurse can do to avoidputting the patient in
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
As defined by the US Food and Drug Administration (FDA, 2015), a medication error is “any preventable event that may cause or lead to inappropriate medication use or harm to a patient.” In order to prevent harm by medications, nurses and nursing students alike are required to adhere to the “seven patient rights,” which help eliminate any possible errors in the medication administration process. These seven rights include: right patient, right drug, right dose, right route, right time, right action and right documentation. However, many medication errors continue to occur because one or more of these rights is either violated, or omitted altogether. Research done by Polifroni, et al. (2003), shows that the most common errors in medication administration are those involving the time of administration and the dosage amount. These errors are often a direct result of the nurse’s increasingly chaotic practicing environment. Increasing nursing shortages create a larger patient load for each nurse, making is easier for the nurse to get distracted and inadvertently miss the dose,
Medication mistakes is a critical global issue and the utmost principle widespread dilemma that terrorizes patient safety that might spearhead to disability or death if not detected, and medication error are virtually never deliberate and regrettably occur in healthcare
Nurses are the health care professionals that collect and prepare medications for patients. They examine the doctor’s orders to see what medications patients are prescribed. Errors can occur in the distribution of these medications. As a result, the nursing ethic of do no harm may not occur. According to McIntyre, Thomlinson, & McDonald, “nurses are held in high regard” (2006, p.360). As such, nurses must keep this positive concept, as we are the health professionals that care for people when they are at their most vulnerable. There is a need for nurses to reflect back to nursing school and use the information taught to guide decisions regarding medications and their administration. This paper will examine medication administration errors
The administration of medication can be associated with a significant risk with it is recognized as a central feature of the nursing role. It should continue in order to avoid a possible medical malpractice continuous care. Nursing staff have a unique role usually given to patients to manage their medication and responsibilities, then they can report these identified medication errors. Some of the most distinguishable events can be related to errors in professional practice, prescribing, dispensing, distribution, and education or monitoring. Since medication errors can arise at any state of the administration process, it is essential for nursing staff to be attentive of the most commonly encountered errors. For the most part, the common of the perceptible aspects related with medication errors are due to minimal awareness about hospital policies, inappropriate implementation or latent conditions (Farinde, n.d).
Medication administration is the foremost responsibility of a nurse (Sung et al. 2008). Pronovost et al. in 2005 mentioned that errors occur during medication administration which jeopardise in patients safety. Medication errors are the most common type of errors in the healthcare centres ultimately resulting in the high financial costs to
Going back to 2007, there were nearly 73,000 medication errors reported to the National Patient Safety Agency. 73,000 errors is far too many regardless whether there was harm done to the patient or not (Nute, 2014). According to a study done in 2009, the majority of the errors came from unclear or wrong dosage, wrong medication, delayed or omitted medication, wrong route, and giving medication to the wrong patient, with unclear or wrong dosage being the number one cause. One of the things that is being implemented now is the use of the five rights. A nurse or healthcare provider is required to administer the right patient the right medication at the right time using the right route and the right dose. This appeared to be the perfect solution to the problem until further studies were performed. The five rights provided some reduction in the number of medication errors but it did not solve the many steps that are to be taken before administering the medication to the patient. One of the most important tasks that needs to be met is knowing the medication before it is
About1.5 million people are harmed yearly in the U.S. because of medication errors, The National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) defines the meaning of medication error, they define it 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…”. (Stoppler, 2015) It is a serious topic in the nursing field that should be addressed and prevented.
Medication errors occur more often than they should. It is recorded that medication errors occur in children every eight minutes or in every 25 out of 1900 children. Adults older than age of 65 are seven times at a greater risk of being victim of medication errors than those adults under the of age 65. What is a medication error? A medication error is a event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare professional, patient, or a consumer. The patient has to actually receive the drug in order for it to be considered a medication error. Detrimental patient outcomes are associated with medication errors. A few of the many harmful effects include medication overdose, stroke, heart attack, organ damage, harm to fetus, paralysis, and death. The numbers of occurring medication errors are staggering but they can be prevented. There a precautions to take in order to safely administer and prevent medication errors, which requires following the “six rights of medication administration”. These six rights are as followed, right patient, right drug, right dose, right route, right time & date, and the right documentation.
Essentially the faith of all the nurses administering medications in that hospital laid in the accuracy of the system being utilized. It is important for nurse leaders to assure the understanding to all nurses that the IT system is not a flawless system. Nurse’s must be aware that the basic nursing fundamentals must still be practiced. In this case, if the nurse utilized the basic nurse application of the Eight Rights of medication administration: the right drug, the right patient, the right dose, the right time, the right route, the right reason, the right response, and the right documentation (Nursing 2013 Drug Handbook, 2013) the medication administration error may have been avoided. It is important for nurse leaders to educate nurses to report glitches in the IT system right away if they are found. Even if the glitch may seem small, it could potentially cause a disastrous outcome. Providing an easily accessible person to report these system errors when found, assures patient safety, the best patient outcomes, and a safe working environment for the healthcare team. Lastly, nurse leaders should assure that nurses have a clear understanding on how to properly use the HER system. Accidental deletion of patient information or accidental omission of current patient information may cause safety related issues and an
“The National Coordinating Council for Medication Error Reporting and Prevention 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...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” ("10 Medication Errors . . . and How You Can Prevent Them”). Medication errors account for approximately 1 out of 131 outpatient and 1 out of 854 inpatient deaths ("10 Medication Errors . . . and How You Can Prevent Them”). Although these medication errors have started to become recognized, the problem continues to persist.