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.
In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.
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
It is the goal of all healthcare providers and organizations to provide quality care to all patients without error. The truth is, even healthcare providers make some mistakes. The question is, when an error occurs who is to be held responsible? Is it, the nurse who administered the wrong medication, due to being overworked and lack of staff to help? Or is it the Healthcare Organization (HCO), because they should have fixed the staffing issues. There are so many factors that contribute to an error. I believe each situation should be properly investigated, before placing blame where it should or should not be placed.
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
In today’s modern society, patient safety in the hospital setting has evolved to a number one priority. Medication errors account for a great deal of incidents in hospitals. Practicing healthcare professionals must be competent when administering medications; therefore, The Joint Commission has implemented National Patient Safety Goals to prevent patients from being administered the wrong medication. Also, the National Patient Safety Goals holds the practicing healthcare professional accountable for the medications that are given to patients. We intend to explore the similarities and differences in how Florida Hospital Zephyrhills and Edward White Hospital accomplishes the National Patient Safety Goal of Medication Safety and
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).
Drug mishaps initially happen to be of critics and detractors of all patients. Pharmaceutical errors and mistakes are preventable episodes that happen because of a blunder during the time spent endorsing, administering, and administrating. Extreme cases frequently prompt negligence claims. The danger variables for drug blunders is talked around and also proposed systems to control them. In the coming of innovation, the medicine organization environment is
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
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).
Medication errors are a reoccurring issue that has plagued the medical field since the beginning of drug administration. In order to understand how to handle medication errors, one must first understand what a medication error is. The concept of medication error can be defined as: “any preventable event that may cause or lead to inappropriate medication use or harm to a patient” (Kee, 2012, 125). Examples of medication errors include: misreading a patient’s medical file, not clarifying illegible prescriptions, an incomplete patient assessment, confusing look-alike and sound-alike medications, and lack of better understanding if a medication can be crushed or split. To better understand medication errors and medication safety one must understand the impact it can have on the medical community and patient care, ways to prevent medication errors, and what should be done in a situation where a medication error has occurred.
The National Patient Safety Agency (NPSA 2010), defines a drug error as ‘any preventable event that may cause or lead to inappropriate use of patient harm. Although not all drug errors have lead to patient harm it is important to recognise that if a mistakes has been
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.
Risk factors for harmful medication errors reported include the usage of institute of safe medication practices (ISMP) high alert medications, inaccuracy of delivery devices and during the prescription phase of the medication administration process. According to the Harvard Medical Practice study 30% (thirty percent) of patients with medication related injuries died or were disabled for more than six months. (Carlson, 2001, p.18.)
Reporting errors can strengthen the processes of care and also enhance the quality of care. To effectively avoid further errors that can cause harm to patients, improvements must be made on the incidents or events reported in reporting system. Reporting errors can help the organizations better understand what happened, identify the factors that cause the occurrence of errors or incidents, determine its frequency and predict whether it could happen again and find an intervention to prevent or to