Medication errors are one of the most costly errors for a hospital to encounter. According to the Institute of Medicine (IOM), there is an estimate of over 90,000 people who dies annually as a result of hospital mistakes arising from medication errors. The IOM estimates that medical errors alone cost the U.S. over $37 billion each year. In resents studies, it has been revealed that preventable adverse events (PAEs) lead to 350,000 patients who seek care in hospitals. The CDC reports that these figures make medication error to be the third leading cause of death second to heart disease and cancer. The purpose of this case study is to bring awareness to staff and educate them about the seriousness of this matter. Sentinel outcomes within the hospital settings are preventable with better patient’s outcomes projected. The Chief Nursing Officer (CNO) must remain knowledgeable and direct change that will promote a Healthy Reliability Organization that is supported and guided by the practice of evidenced-based medicine. The CNO can address leaders within the organization to tackle such an issue now before further damage is done. This will allow the organization to incorporate a more comprehensive approach to improving care within the hospital with better quality outcomes implemented. Hospitals by adopting the TeamSTEPPS principles can promote high-quality patient care that is supported by evidence-based practices (Crane & Crane, 2006; Kohn, …show more content…
Proper communication techniques such as the one that support Situation, Background, Assessment, Recommendation and Request (SBAR) should be used. Nurses must also remain vigilant when speaking with physicians and relaying verbal orders. Such orders should be done through the use of closed- looped communication with fewer errors and sentinel outcomes observe (TeamSTEPPS 2.0,
Excellent outline for your quality improvement initiative that addresses medication errors. I like how you describe the closed-loop medication administration process that includes all members of the interprofessional team. Your references are also well researched and current. From the outline, it is unclear what the barriers and implementation strategy are to reduce medication errors. One suggestion I would make is to look at the grading rubric. There are four main points that the rubric requires to complete the objectives for the paper. I usually create headings that align with the rubric, this helps me organize my thoughts and to meet the objectives of the assignment.
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.
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.
There are many different variables that go into a scenario of a medication error. Nurses carry a huge role with ensuring patient safety during a medication administration. According to Härkänen, Ahonen, Kervinen, Turunen and Vehviläinen-Julkunen (2015), the study that was performed on a medical surgical floor yielded information that allows administration to examine plausible reason behind the medical errors. The area within nursing that need to have an improvement is reducing patient medical errors due to patient to nurse ratio in combination with reducing distraction and acuity. The study that performed by Härkänen et al. (2015), observed that patients had medications of upwards to 20 regular medications, and giving them 3 times minimally. Nurses encounter many types of distractions during the times that they are administering medication. The first issue with this is that the patient has high acuity
The issues addressed are Findings 1 and 3: Finding 1 is patient medication errors are up and there is a perception of shady hiring practices and playing favorites. All employees are responsible for compliance. Policies and professional standards exist for the medical profession. The challenges will be reintroducing employees to Federal and state law that govern the profession. For hiring practices and playing favorites the challenges faced are the lack of compliance reporting structure or training for understanding compliance. There is a perception that work rules are not being enforced. Finding 3 is high job turnover and low employee morale. The challenges faced will be building communication strategies, building confidence in leadership,
Nurses are responsible for multiple patients on any given day making medication errors a potential problem in the nursing field. Medication administration not only encompasses passing medication to the patients yet begins with the physician prescribing the medication, pharmacy filling the correct prescription and ending with the nurse administering and monitoring the patient for any adverse effect from the medication. According to the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP), ‘A medication error refers to any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional,
Medication errors are among the most common medical errors, harming and costing millions of patients in the world very year. Prevention of medication errors is, therefore, a high priority worldwide. Nowadays, various information technology (IT) systems are widely used to prevent and reduce medication errors. Computerized physician order entry (CPOE) with patient-specific decision support is one of the most powerful IT systems used by physicians to improve patient safety in various healthcare settings. As an example, application of CPOE systems has significantly reduced errors related to dosing of psychoactive medications. Pharmacy dispensing systems, including drug-dispensing
The health information technology (HIT) topic selected is medication errors. In his March 17, 2017 article titled, “Poorly Implemented IT systems lead to medication errors” author Evan Sweeny discusses a the findings of Pennsylvania Safety Advisory which found that information technology (IT) systems implemented to prevent medication errors, may in fact contribute their occurrence. This paper will examine how HIT can both prevent and contribute to medication errors. The following elements are included, introduction, the rationale for selection, positive and negative impact of health information technology on medication errors, how informatics skill was relevant in assignment development, and
Use special procedure for the use of high-risk medications using a multi-disciplinary approach, including written guidelines, checklists, pre-printed orders, double-checks, special packaging, special labeling, and education. (Institute of Medicine (IoM) Strategies Regarding Medication Practices, 2005).
In today’s current fast-paced and demanding field of heath care, medication administration has become complex and time-consuming task. Approximately one-third of the nurses’ time is used in medication administration. There is much potential for error because of the complexity of the medication administration process. Since nurses are the last ones to actually administer the medication to the patient therefore they become responsible for medication administration errors (MAE). Reasons for MAE may include individual factors, organizational factors or system factors. This paper will discuss the root causes analysis of MAE and strategies to prevent them.
For many patients the scariest part of being in the hospital is having to rely on other people to control your life changing decisions. One large part of this is the medications one is given while in our care. I can only imagine what it must be like for patients to have a stranger to come in and start administering drugs to me. This would be especially scary if I did not know what these medications did, or what negative effects could be caused by taking them. Unfortunately, the fear of medication errors that many patients have are not unfounded. Estimates range from 1.5 to 66 million patients a year have medication errors occur while they are in the care of health care professionals. Considering all of the technology we have at our
An error is one of the vital parts of human life. Hospitals are areas with very chaotic systems and as health care is growing more steadily, it is becoming complex in nature and more sophisticated technologically. Therefore, medical errors are bound to happen. Administrators, physicians, and nurses, are advocates of patient safety and safety is one of the highest priorities during the provision of care. A report from Institute of Medicine (IOM) claims that between 44,000 and 98,000 die annually due to medical errors (Alexander, Cheryl Ann 2014). Medication errors can lead to adverse outcomes such as increased mortality, extended period of hospitalization, and amplified medical expenses. Although the health care team can cause medication errors, nursing medication errors are the most common. Moreover the workload of the nurses combined with more prescription
There are several definitions which have been given to demonstrate medication errors. Indeed, medication errors might defined as that lead to appropriate drug use or patient harm.
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