For the incident I do notice that there are other contributing factors for this error to take place such as there were no guidelines on administration of high alert medication. In order to have proper understanding on high alert medication, a guideline is indeed crucial to assist the nurses administering safe treatment. High alert medication is known to have the highest risk of medication administration that is been carried out by nurses. Besides that based on the incident the nurse had stated that she assume the no ‘5’ was ‘2’ and this is due to poor handwriting by the doctor. If only the hospital had a Electronic prescribing (E-prescribing) system, than this incident surly could have been prevented. Conclusion It is clear that from the …show more content…
If at any given situation if only if happened again I need would be calmer in order to be rational and fair to my own team members. By doing this I believe I will be able to handle this type of situation better. I also learned to look at incidents in a positive way rather than just looking at one side of the card as this will lead to negative impression as well as being bias. I realized that as a human we can make mistake but should learn from it and never to repeat it again. I do wish that I could rewind back the clock and change the whole situation but that I could never be able to do so but I can change the future and this is the beauty of reflection …show more content…
Researchers had highlighted that in order to prevent medication errors, hospital organization should have an established guidelines and computer prescribe system is highly recommended. The development of guidelines involves many parties contribution such as pharmacy, doctors, nursing, risk management team and the hospital organizational team (Grossman, Gerland, Reed, & Fahlman, 2007). In Malaysia our Ministry of Health had came up with a very detail and comprehensive guideline know as Guideline on Safe Use of High Alert Medication done by Pharmaceutical Services Division, Ministry of Health Malaysia. When I read this guideline I realize my hospital don’t even have a Standing Operating Procedure (SOP) on administration of medication. I strongly believe this is one major contributing factor why the medication error took place in my practice area. A key point that I notice in this guideline is that, the nurse who is administrating medication should have knowledge especial the risk involved in this group of drugs and must have had read the guidelines on Medications
...estions if not 100% sure of something or use a double checking system. When a nurse is administrating medication, they should use the ten rights of medication administration (right patient, right drug, right route, right time, right dose, right documentation, right action, right form, right response, and right to refuse). Nurses should always keep good hand hygiene and always wear appropriate clothing to prevent from the spread of disease. Good communication with patients and healthcare team members is also key to success. Keeping on the eye on the patient within an appropriate time is important. If the patient ever seems to be looking different than their usual self vitals should be taken immediately. Encouraging patients to ask questions if they are unaware of something can prevent errors as well. Nurses should make sure the patient is on the same page as they are.
Nurses were the professional group who most often reported medication errors and older patients were those most often affected in the medication errors reports analyzed for this study (Friend, 2011). Medication error type’s revealed omitted medicine or dose, wrong dose, strength or frequency and wrong documentation were the most common problems at Site A where the traditional pen and paper methods of prescription were used; and wrong documentation and omission were the most common problems associated with medication errors at Site B where the electronic MMS was introduced (Friend, 2011). Reports of problems such as wrong drug, wrong dose, strength or frequency, quantity, wrong route, wrong drug and omitted dose were less frequent at Site B (Friend, 2011). The reduced incidence of omission errors at Site B supports suggestions that an advantage of the MMS is easy identification of patient requirements at each drug round time slot. Despite the finding of less omission errors at site B where the MMS had been introduced, there was a relatively high frequency in the incident reports of medication errors related to both omission and wrong dose, strength and frequency at both sites (Friend, 2011).
Some method such as audits, chart reviews, computer monitoring, incident report, bar codes and direct patient observation can improve and decrease medication errors. Regular audits can help patient’s care and reeducate nurses in the work field to new practices. Also reporting of medication errors can help with data comparison and is a learning experience for everyone. Other avenues that has been implemented are computerized physician order entry systems or electronic prescribing (a process of electronic entry of a doctor’s instructions for the treatment of patients under his/her care which communicates these orders over a computer network to other staff or departments) responsible for fulfilling the order, and ward pharmacists can be more diligence on the prescription stage of the medication pathway. A random survey was done in hospital pharmacies on medication error documentation and actions taken against pharmacists involved. A total of 500 hospital were selected in the United States. Data collected on the number of medication error reported, what types of errors were documented and the hospital demographics. The response rate was a total of 28%. Practically, all of the hospitals had policies and procedures in place for reporting medication errors.
One of many nationwide initiatives to help reduce the occurrence of unnecessary medical errors and adverse events is the use of the integrated Clinical Decision Support System (CDSS). A CDSS is a system that provides the right information to the right person in a right format through a right channel at the right time of workflow to facilitate better decision-making by clinicians, reduce errors, and also to prevent adverse events (AHRQ, 2008). This proposal is a case based CDSS system that provides point of care clinical decision support, ensures five rights of medication administration (right person, right drug, right dose, right time and right route), and is designed to prevent or reduce the occurrence errors and adverse events at Perpetual Order of Saints Hospital (POSH).
Every day there is a constant trust adhered to many different people in the profession of Nursing—the decision of what will help patients in terms of medicine, and the confidence to make these decisions. One false act or one slight misdiagnoses of medication to a patient could be the prime factor in whether the patient lives or dies. Nurses in hospitals across the country are spread thin, and thus makes the probability of mistakes higher. If a medicinal dose is off by even one decimal a patient could die, so the only real answer is for nurses to not be afraid to ask for assistance, always follow procedure and voice opinion is they feel something is wrong.
Medication errors made by medical staff bring about consequences of epidemic proportions. Medical staff includes everyone from providers (medical doctors, nurse practitioners and physician assistants) to pharmacists to nurses (registered and practical). Medication errors account for almost 98,000 deaths in the United States yearly (Tzeng, Yin, & Schneider, 2013). This number only reflects the United States, a small percentage in actuality when looking at the whole world. Medical personnel must take responsibility for their actions and with this responsibility comes accountability in their duties of medication administration. Nurses play a major role in medication error prevention and education and this role distinguishes them as reporters of errors.
The main quality initiative affected by this workaround is patient safety. The hospital switched to computer medication administration as opposed to paper medication administration documentation because it is supposed to be safer. So, when the nurse gets the “wrong medication” message the computer thinks something is wrong, this is a safety net that is built into the computer system. If the nurse were just to administer the medication without any further checks, he or she would be putting patient safety on the line. The policy involved that pertains to this workaround is the “8 rights of medication administration”, which are: right patient, right medication, right dose, right route, right time, right documentation, right reason, and right response (LippincottNursingCenter®, 2011). Each nurse it taught these eight rights of medication administration in nursing school, therefore it is a nursing policy. When this workaround occurs the nurse should use his/her judgment before “scan overriding” and ensure these eight checks before administering the
...nform the previous shift nurse who has made a mistake and conducted the medication error. Along with informing the co-worker, a right decision would be following the chain of command and report to the next person in authority at the hospital.
The topic of this article is medication error related to chemotherapy drugs. Forty percent of medication errors have been related to chemotherapy drugs. It is imperative that the nurses are properly trained on these medications and fully understand what is being administered before giving it to the patient as well as know what the proper dose is before administering anything to the patient. More importantly the nurse must pay close attention to their patient’s response to the chemotherapy given to the patient or it could lead to a serious injury or death.
A newly employed critical care nurse was just about to finish a 12-hour night shift when she realized she had one more patient to administer medication to. It was the busiest Friday night shift she has ever worked due to a poor nurse-patient ratio, and the workload felt impossible. She gave her last patient the properly prescribed medication, but failed to notice that the physician hastily wrote an updated dosage for a high risk medication, Digoxin. The patient’s heart rate began to slow down and life-saving procedures had to be performed. Medication errors are “any preventable event that may cause, or lead, to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer (About Medication Errors, 2015)”.
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 the nursing profession, taking up to forty percent of a nurse’s time in providing nursing care (Fowler). Consequently, nurses are commonly held accountable for medication errors. To improve the safety of a vital aspect of nursing care, bar code scanning was introduced to reduce errors in medication administration. Although bar code scanning has its advantageous aspects, there are also disadvantageous qualities.
Baccalaureate nurses are responsible for providing and ensure our patients safety. The knowledge from others mistakes can help informs nurses of extra precautions that we can take to ensure our patient’s safety. Risk Analysis and Implication for practice course helped me understand the steps I as a nurse can take as well as the facilities I work for to help reduce the number of medication errors that occur. Interviewing the pharmacist help me get a better insight to what facilities already have in place to help prevent medication errors. However like most things you have to have educated and compassionate caring staff to enforce and follow the guidelines set in place.
Firstly, nurses are expected to practice evidence-based health care hence a mastery of information about the essential and safe dose of drugs for a patient is very important for a nurse. Consequently, it could be the determinant between the life and the death of the patient. Pharmacology is a discipline which is mandatory for the nurse to excel in to be efficient in discharging his/her duties. Understanding which drug to use, the right dosage, the expected side effects which may occur and the contra-indications of the various drugs are key in the preservation of
Care planning is one of these tasks, as expressed by, RNCentral (2017) in “What Is a Nursing Care Plan and Why is it Needed?” it says, “Care plans provide direction for individualized care of the client.” A care plan is for an individual patient and unique for the patient’s diagnosis. It is a nurse’s responsibility to safely administer a patient’s medication prescribed by the doctor. Colleran Michelle Cook (2017) in “Nurses’ Six Rights for Safe Medication Administration,” she says, “The right patient, the right drug, the right dose, the right route and the right time form the foundation from which nurses practice safely when administrating medications to our patients in all health care settings.” Nurses must be safe when dealing with medications, and making sure they have the right patient. Nurses document the care that is given to their patient, as said by, Medcom Trainex (2017) in “Medical Errors in Nursing: Preventing Documentation Errors,” it states, “Nurses are on the front lines of patient care. Their written accounts are critical for planning and evaluation of medical interventions and ongoing patient care.” Nurses must provide an exact, complete, and honest accounts of everything that happens with a patient. Doing this allows for the proper evaluation, and medical interventions for the patient. The typical tasks a nurse involves care planning, administration of treatments and medication, and documenting the care given to a
• The computer is becoming the key factor of hospital pharmacy practice. Enhancement of computer technology is essential to assist the hospital pharmacist in keeping all relevant data in order to provide optimal oversight of drug therapy. As more data become available on drugs, the factor which place the patient at risk for developing reactions to drug, pharmacist must place less reliance on committing all facts to memory and recognize that the computer is a necessary solution to optimizing patient care.