Patient Safety: A Case Study

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

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 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.

Safety is a small measure that can make a big impact on a patient in the clinical setting. In some cases, it can even cost patients their lives. According to the Online Journal of Issues in Nursing, safety is defined as a tool to minimize risk of harm to patients and providers through both system effectiveness and individual performance (Barnsteiner, 2011). Safety problems can range from the nurse not knowing how to work certain equipment, or the nurse recording values wrong because he or she is distracted. Either way, these safety issues impact the clinical setting in a negative way. In order to have a functional, safe clinical environment, time and money must be spent to keep the hospital in working order and the nurses in the correct mindset.

In our nursing practice, the nurse is required to hold essential skills of clinical judgment and be a patient advocate to ensure the safety and the well-being of the patient we care for. Patient safety can be compromised if nurses are not able to identify potential issues thru assessment of the patient's sign and symptoms. Patient safety can also be compromised if nurses are afraid to speak up for our patient and question what we think or feel are unsafe acts or orders.

Woten (2016) attributes, National Patient Safety Goals (The Joint Commission, 2016): Medication Reconciliation – an Overview acknowledges effective communication is a driven force to accurate medication reconciling. Communication to patients, families, professional to professional provides honesty along with direction in role responsibilities. Poor communication was recognized from a study at Mayo Health system, reporting, “medical information at transition points was responsible for as many as 50% of all medication errors in the hospital and up to 20% of ADEs”(Vogenberg & DiLascia, 2013). The evidence in transitions throughout care directly connects to communication validating how medication lists, if not updated or accurate cause harm to

WHO, 2011; AHRO; 2013; EMA, 2013; Parry, et al., 2013; NRLS, 2014; Medication management and administration is one of the major responsibilities of the nurse in a healthcare organizations. It is a difficult task and involve several phases such as prescribing, transcribing, supplying, ordering, dispensing, calculating, storing and administering (Dilles, Elseviers, Van Pompey, Van Bortel & Stichele, 2011).

Medication errors originate in multiple ways such as “professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use” (U.S. Food and Drug Administration, 2015). Many patients may be quick to criticize medication errors to be the responsibility of the professional who administers the medication rather than the manufacturing, production and data entry processes.

Another causative issue to medication error was poor staff knowledge about medications. 46% (n=32) of registered nurses and 37% (n=15) of student nurses stated that not having enough knowledge about medications increases the risk for creating an error. It is essential for the person passing meds to identify potential side effects, the drug type, contraindication and it interactions to reduce the patient may encounter for taking the medication. The qualitative review of registered nurses reinforced this issue.

Medication error can occur as a result of increased distraction. The study examined the nurse’s distraction

As previously mentioned, the nurses responsible for the medication errors experience a tremendous amount of professional and personal guilt. The entire process of administration of medications involves multiple factors and many members of the health care team. Research by Leufer and Cleary-Holdforth (2013) supports that medication errors can largely be linked to healthcare professionals and the systems of health care within which they operate. With this being said, nurses ultimately have the final say and are the healthcare professionals from prescribing to administration of

This transformation was met with resistance from several physicians and staff members who were not willing to change the method for entering and receiving orders. Computerized Physician Order Entry (CPOE) systems are remarkably effective at reducing the rate of serious medication errors. A study led by David Bates, M.D., Chief of General Medicine at Boston’s Brigham and Women’s Hospital, demonstrated that CPOE reduced error rates by 55% — from 10.7 to 4.9 per 1000 patient days. Rates of serious medication errors fell by 88% in a subsequent study by the same group (Preventing Medication Errors in Hospitals (n.d.).

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.

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

Medical errors caused by human oversight are the main issue inside Emory Healthcare. In 1986, it was calculated that 37% of the patient cases had medication treatment fault. The problems are due to the lack of standard for orders by physicians. Physicians would place orders by hand writing, and then they would call a nurse and ask him/her to write the