Health Care Case Study

Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long-term care settings across America (Institute of Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while ADEs may result from oversights related to prescribing or dispensing, 26-32% of all erroneous drug interventions occur during the nursing administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden for health care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components in allaying drug-related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon quality control.

Patient information, drug instruction, communication amongst medical staff member, drug labels, patient literacy and the nurses knowledge of the medication are just to name a few. It only takes one of these aspects to be incorrect for a medication error to harm a patient, causing life changing or even life threating complications. Other circumstances that may contribute to medication errors include fatigue and staffing shortage. Nurses reported that fatigue, stress and understaffing increased the risk of making a medication error. Anderson, (2010). Majority of clinical staff work 12 hours shifts. Due to patient acuity and inadequate staffing, workload and hours many times are increased. sleep deprivation has been shown to be a major factor in medication errors. The diminished hours of sleep effect clarity of thought causing room for errors. Novice nursing has also been a component of many medication errors. Unexperienced nurses are overwhelmed with the increased workload and new responsibilities, which places them in danger of making these dangerous inaccuracies. While rushing to pass meds in a timely manner, critical medication errors reportedly made. Actively adhering to the five rights of medication administration measures while distributing patient medication can inherently cut down on errors made in the nursing

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

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

As previously mentioned the institute of Medicine report dated 1999, every year 44,000 to 98,000 patients die from medical errors. Almost 7,000 of them were medication errors that could have been prevented (ORH, 2004). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Pubmed, 2012). Medical errors are not a new issue and have been around for a long time. The questions come to mind are how does the problem of medical errors affect our healthcare delivery system? Also how can these medical errors be prevented and reduced?

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.

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.

As a result medication errors are costly and seem to be relative to the staffing of nurses. Given that nurses make up such a large segment of the staff population, it is important to identify with the factors behind these medication errors.

Medication errors compromise patient care and potentially leads to increase in debt for the institution. The source of errors are numerous

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.

Safety is one of the most important traits of providing care to a patient. Medical mistakes are a growing concern within the health care field, as each year an estimated 400,000 lives are lost to preventable medical mistakes (James, 2013). One important subset of medical mistakes is medication errors. 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” (National Coordinating Council for Medication Error Reporting and Prevention, 2014). Health care

During the interview, R. Crowdis emphasized on different safety measures nurses can take to protect patients from medication errors. These include verifying and clarifying any orders that look ambiguous or that do not match the patient’s needs, use the five rights of medication, always scan the medication, have two separate nurses verify high risk medications, and follow hospital policy when wasting narcotics (R. Crowdis, Personal Communication, June 11, 2016). The five “rights” of medication R. Crowdis is referring to are the right patient, right medication, right dose, right route, and the right time (Archer, 2015, p. 394: Centre for Policy Agency, 2011). Every medication must be scanned and if unable to, then notify the unit director and pharmacy of the issue. Always scan each individual pill, even if there are multiples of the same kind; one pill may be expired, a different medication, or same medication but different dosage that was accidentally stocked by pharmacy. Watch for system lags or additional screens that appear for this may cause errors is medication administration when scanning. Athanasakis (2012) also recommends reducing distractions and interruptions during medication preparation and administration to help in the prevention of medication errors (p. 775). Having excess family and friends step out of the room, informing the patient of the medication, what it does, and double checking when the last dose was given are additional measure a nurse should take in the prevention of any

This paper will focus on the role of the nurse, and will identify two serious flaws in the healthcare administration process that leaves patients vulnerable to these medication errors; while also offering research suggested solutions to help prevent many of these errors in the future.

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