Medication Safety 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.

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

In the UK, there are more than 1 billion scripts prescribed and dispensed every year (HSCIC, 2013). There are over 12,000 pharmacies in the UK, and approximately 1.6 million people visit a pharmacy every day (HSCIC, 2013). It is therefore natural to assume that between these 1 billion prescriptions, an error or mistake will be made. Current studies suggest that of all the dispensed medicines, there are approximately 0.01-3.32% errors made in community pharmacy and 0.02-2.7% in hospital pharmacy (James et all, 2009).

In Australian hospitals medication administration errors make up 9% or 1 in10 of all medication administrations. These errors include wrong doses, wrong intravenous infusion rates and errors made by prescribing doctors. Errors on discharge of patients were increasingly higher with up to 2 errors per patient related to doctors transcribing discharge medications (Roughead, Semple, & Rosenfeld, 2016).

According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year. An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer. To prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The “Rights of Medication Administration” helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.

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

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

One of the standards that has been implemented is Standard 4: Medication Safety. The Australian Commission implemented this standard with the intention of ensuring that competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and monitor the effect. (Australian Commission on Safety and Quality in Health Care, 2012) In healthcare, one of the most common treatments is medication. As a result of this, there are many incidences of error, many more than any other healthcare interventions. According to the Patient Safety Network (PS Network, 2015) medication errors account for nearly 700,000 emergency department visits and 100,000 hospitalizations each year. Medication errors are often a result of the unsafe and poor quality practice of healthcare professionals or system errors. Medication errors are costly and many are avoidable. For this standard

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).

Safe medication practices are key to every nurse since it results to safe medication administration. When medication is not administered correctly it results to adverse drug event which refers to harm to the patient that includes mental harm, physical harm, or loss of function which is as a result of a medication error (practices, 2017). Medication errors occur when a mistake is committed by a person administering medication and in order to avoid these errors safe medication practices need to be adhered to. Some of these

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

Research shows that medication error in hospitals and other health care settings leads to 373,000 preventable adverse drug events (ADEs) per year and that these events would increase to 478,000 within 20 years in the absence of additional preventive measures (Federal Register, 2004).

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

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

Since the perception of patient safety has arisen, many medical organizations were striving to improve medication safety. Emory Healthcare, the largest and most comprehensive health care system in Georgia, was one of them who were seeking ways to prevent medication errors. In recent years, some