Interruption During Medication Errors

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.

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.”

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

In healthcare today, when hospitals are judged upon patient safety standards, it is critical to prevent errors involving medication administration. Distractions while preparing and administering medications, has been report as one of the leading causes of medication errors. Distractions while nurses are administering medications can lead to poor patient outcomes and even sentinel events. Nurses and nurse managers are responsible for maintaining a unit with minimal distractions. When distractions are minimized throughout medication administration process, a decrease in medication errors will occur and lead to increased patient outcomes.

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

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

Biron, Lavoie-Tremblay, and Loiselle studied the number of work interruptions that occurred during medication preparation and administration. The observational study followed 18 nurses during 102 medication rounds. The study found that the main source of interruption were nurse colleagues. Other sources of interruptions during preparation were missing meds, MARs, keys for the narcotic cabinet. Sources of interruptions during administration were unplanned tasks, secondary, and unscheduled tasks. The authors state that limiting sources of frequent interruptions should be targeted. The authors hold PHD’s and have a reference listing of 27 articles.

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

This study described discharge prescription medication errors written for emergency department patients. This study used content analysis in a cross-sectional design to systematically categorize prescription errors found in a report of 1000 discharge prescriptions submitted in the electronic medical record in February 2015. Two pharmacy team members reviewed the discharge prescription list for errors. Open-ended data were coded by an additional rater for agreement on coding categories. Coding was based upon majority rule. Descriptive statistics were used to address the study objective. Categories evaluated were patient age, provider type, drug class, and type and time of error. The discharge prescription error rate out of 1000 prescriptions

The article “Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration” by Flynn etal, (2016), talks about a study conducted a medication improvement project in a progressive cardiac care unit, and implemented a Nurse uninterrupted passing medication safety (NUPASS) guideline. Common interruptions identified by nurses in the study that contributed to medication error during medication administration included, phone calls, access to sources or equipment out of reach such as missing medications or health related supplies, nurses interrupting each other with non-related medication conversation, or patient related interruptions. The NUPASS guideline recommended increasing teamwork during busy hours, the study results show the percentage of medication errors have decreased after implementing these

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).

There are a lof ways to prevent medication errors for example ISMP is something being used to prevent those medication errors, and it stands for the Institute for Safe Medication Practices and it is based on suburban Philadelphia. ISMP started about 35 years ago and it has always been the foundation of its medication error prevention efforts a volunteer practitioner will use error reporting-program to learn about all the errors that happen across the nation part of their job is to understand all the causes and share all the lessons that will help the healthcare community, and they are also responsible for reviewing all the medication error reports submitted by healthcare facilities to the Commonwealth of Pennsylvania Patient Safety Authority.

Causes of medication errors are important to recognize and evaluate otherwise patients will not be receiving quality care. Nursing students errors were mostly made under the field focused on the five rights of medication administration (Wolf, Hicks, & Serembus, 2006). Patient safety is at risk when student nurses do not know how to use the six rights of medication administration. If nursing educators and experienced nurses do not change their attitudes, or seek help with reporting errors, future nurses will not understand the severity of their actions when they fail to report a medication error.

The population that is affected by medication errors are everyday people. They are vulnerable patients who reside in assisted or residential facilities, while relying on non-licensed staff members to administer their medication or provide care. While the clients are vulnerable, the rely solely the fate of others for medication administration as well as care assistance.

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