Medication Errors Case Study

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.

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

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).

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.

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.

Safety is a priority to delivering healthcare, however, medication errors have been identified as a safety issue in healthcare. The Institute of Medicine (IOM) has released two landmark reports that identify adverse outcomes that occur yearly from medication errors (Kohn, Corrigan, Donaldson, 2000; Institute of Medicine [IOM], 2001). Because nurses are intimately involved in providing patient care and medications, as a result of these reports attention was directed at the nursing profession to improve the mathematical competence of nurses. Therefore, it is imperative that nursing students are competent in converting between measurement systems, identifying common pharmacological abbreviations, methods of medication administration, reading medication labels, and calculating medication dosages in order to provide safe care. In the article, Teaching the Culture of Safety, the American Nurses Association (ANA) affirms that pre-licensure programs should include education on patient safety and system vulnerabilities that is expanded on throughout all nursing education and practice to promote a culture of safety (Barnsteiner, 2011). Therefore, the implementation of early medication calculation in a nursing program helps establish fundamental nursing mathematical skills to help nursing students become competent in medication calculation skills and combat medication errors and promote the delivery of safe nursing care (Newton, Harris, Pittilgio, & Moore, 2009).

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 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.

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).

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

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.

Adverse drug events are the sixth leading cause of death in the United States and represent a significant financial burden to healthcare institutes at an estimated cost of $5.6 million per hospital per year (Meguerditchian N, Krotneva, Reidel, Huang, & Tamblyn, 2013). According to The Joint Commission (2006), medication reconciliation is the process of comparing a patient’s medication orders to all of the medications the patient has been taking. This reconciliation is done to identify and resolve medication discrepancies, which are unintended or unexplained

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

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 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