Multiple System Failures Responsible For The Sentinel Event : Insufficient Drug Information And Inconsistent Independent Double Check System

Patient centered care and patient safety are the most important roles in nursing. “Serious medication errors are common in hospitals and often occur during order transcription or administration of medication” (Poon et al., 2010. p. 1). One important aspect of nursing is drug administration. It is a multidisciplinary task including doctors, pharmacist and nurses. This paper will show evidence that using electronic medication systems instead of paper based systems to administer medication will reduce medication errors.

A mistake can happen at any stage. Although numerous mistake can happen in prescribing stage. According to Choo, Johnston & Manias (2013) most common system failures connected with prescribing errors were a

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,

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

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

When I say this, however, most people would picture the nurse giving the wrong medication due to lack of focus on the tasks at hand. While this could happen, I have noticed during my time at hospitals that the doctor orders are still hand written for the most part. Consequently, they can be very hard to be read legibly much less correctly translated into proper medication dosages. The first suggestion I would give to an organization would be that they required all orders to be submitted securely, by the doctors, to the pharmacy be electronic means.

Bedside Medication Administration (BMV). A BMV system would be helpful in addressing the issue of drug administration. The system would work with a patient’s electronic medical record (EMR) to compile data on the patient’s medications. The program could alert the nurse the proper dosage and different vitals and laboratory results needed before administration. This system would be worth the financial investment because there has been occurrences of improper dosage and negligence of nighttime medication. Drugs are a crucial

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

The problem that the community is experiencing related to medication administration is that there is no system that can be used to check the medication before administering except the RNs and LPNs themselves. Staff members are using picture of patients in the system as a way to identify patients before administering medications. They do not have barcode reader to alert them when they are about to administer wrong medications. The community is aware of this problem and started to use the same process except that the medication is checked by three nurses instead of two after entering the information into the system.

The Institute of Medicine (IOM) report, To Err is Human, highlighted the prevalence and devastation caused by medication errors in the US healthcare system. The 2000 Report declared that the rates of medication errors and subsequent adverse drug events (ADEs) are unacceptable and immediate action to decrease these rates should be a national priority. In a later Report, the IOM committee estimated that nearly 1.5 million ADEs result from preventable medication errors annually, contributing to over $3.5 billion in avoidable healthcare costs.

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.

Medication errors are a very common problem in the healthcare world. They can be very minor errors or they can kill a patient. There have been many new systems put in place to prevent and reduce medication errors but they continue to happen. Several different factors have been looked at to prevent medication errors including computer systems, hours worked, patient to nurse ratio, and years of experience.

One of the many responsibilities of a nurse is administering medications. Improper transcription, dispensing, administering, and reporting can result in medication errors. The article Simple Steps to Reduce Medication Errors recognizes how detrimental errors can be to the patient and the facility (Chu, 2016). An error in medication can lead to an extended stay for the patient, resulting in serious harm or death.

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).

Many were reprimanded by verbal or documentation measures which was placed in their personnel files. One sixth of the hospitals had no documentation or disciplinary action in place. One fourth were either suspended or terminated as their form of disciplinary action, and legal action was never used. Many of the hospitals listed medication errors which had caused harm (42%), and death (40%) in personnel files. However, 34% of the other hospitals did not put any form of documentation of medication errors in any personnel file. There were a difference of three fourths between errors caught and not caught before the medication leaves the pharmacy and reaches the patient.