Unit Dose Packging: A Critical Analysis

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

The author of the article is Walsh, Timothy who has an MD a graduate of Princeton University and of Harvard Medical School. The article was originally published at an organizational site called the American Association for the Advancement of Science, in 1998. The web site was last update on February 24, 2016. The information on the article seems accurate and reliable although sometimes on organizational sites the information is biased toward the

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

Organisational policy and procedures should include how to receive and record medication, safe storage, prescribing, dispensing, administration, monitoring and

as well. Evidence-based practice could be used to see what could have been done to prevent pressure ulcers,

Non care setting - Medications are often stored and administered in a variety of non-health care settings. These settings include: primary and secondary schools, Child day care centres, Board and care homes, Jails and prisons. In all these settings, employees frequently are responsible for handling and administering prescription and over-the-counter medications to clients or residents. Some organizations may employ licensed health professionals to directly manage the medication administration process. However, many of these settings have no licensed health professionals involved. Where medications are stored and administered to individuals, written policies and procedures should address the following: Acquisition of medications (e.g., from parents, caregivers, pharmacies), Specification of which personnel are allowed access to medications and allowed to administer medications to students, clients or residents, Labelling and packaging of medications managed for students, clients

1. In the workplace there is a generic Medication Management Policy and Procedures for Adult Services (Issue 10, 2012) document. This is kept to hand in a locked cupboard, readily available to read. It requires that all Healthcare Staff are given mandatory training and refreshers are provided. Legislation which surrounds the administration of medication includes The Medicines Act 1968, The Misuse of Drugs Act 1971, The Data Protection Act 1998, The Care Standards Act 2000 and The Health and Social Care Act 2001

Labeling issues-The lack of labeling as well as pre-labeling can put the patient at risk. The unit sited for this is the Operating Room.

Medication Reconciliation is defined by the Joint Commission as the process of checking and rechecking a patient’s current medication list to the patient’s orders. Within a MedRec program, three steps must be followed to ensure patients have the correct medications at admission and discharge: Verification, Clarification, and Reconciliation (Greenwald et al., 2010; Ruggiero et al,. 2015). MedRec should not occur once, but multiple times especially when a patient moves from department to department. The more a patient moves, the more liable they are for a medication error due to poor communication. MedRec is done for the simple reason of catching those medication errors and correcting them before they can do any harm (The Joint Commission, 2006). Medication errors effect nearly 1.5 million people who enter the hospital setting in the USA. At least every patient has one medication discrepancy between admission and discharge, which leads to rehospitalizations due to hospital-setting medication errors (Institute of Medicine as cited by Wilson et al,. 2015). With nurses at the forefront of a patient’s medication regime, pressure is put on them to provide the necessary education and safety to prevent medication related rehospitalizations. Included in the causes for medication errors is miscommunication between departments taking care of the same patient (Allison et al., 2015). Many medication errors are preventable by the implementation of electronic orders. The use of electronic

Medication errors are among the most significant cause of patient injury in all types of medical errors (Johnson, Carlson, Tucker, & Willette, n.d). In the nursing profession, medication administration errors occur 34% of the time, second only to physician ordering errors (Gooder, 2011). The introduction of information technology, such as the Bar Code Medication Administration (BCMA), offers new opportunities for reducing medication administration errors. BCMA was developed by the Veteran’s Affairs Medical Center in 1998 to help improve the documentation of medication administration, decrease medication errors and provide

I have done a technical check of a blister pack for one of our patients. This compliance pack was prepared by a new staff. Upon checking I realized that she was missing three pills risedronate, metformin, and one levetiracetam. This mistake could affect the effectiveness and safety of our patient. The person preparing them was informed to pay more attention and double check the blister packs at the end and the errors were rectified.

Both clinicians who are enquiring clinical questions and researchers who are conducting in-depth searches for systematic reviews come across a few

After the interview with my nurse manager, I came up with the PICO question which states: “Does the computerized physician order entry (CPOE) system reduce the number of medication errors compared to the common paper system being used today?” This question is important and I selected it because the population that the Belvoir Community hospital serves includes army officers of all ages both active and retired including their spouses and children. This group includes two sub groups of highly vulnerable persons which include the very young and the very old, who have a high-risk effect for medication errors because the potential adverse drug event is three times greater than an adult hospitalized patient (Levine et al., 2001). CPOE is not a panacea, but it does represent an effective tool for bringing real-time, evidence-based decision support to physicians. Nurses are the last defense level of protection against medication errors, and are solely responsible for the dispensing, administering, and monitoring of medications. In healthcare, computers can be used to help facilitate clear and accurate communication between health care professionals. When using a CPOE system it allows physicians to type in prescriptions right into the device or computer which significantly lessens any mistakes that can occur when

As the number of the cases increase, the just-in-time supply chains or the standard operating procedures would be really difficult to meet the growing demand. Hence the healthcare systems have been challenged to determine the medical supplies that need to be procured. One of the most challenging jobs is to develop a prioritized list detailing all the supplies and essential quantities that need to be stockpiled.