Medication safety and adverse drug events
One of the most consequential professions thought out history is a profession that until recently has been recognized and given the respect the practice upholds is a pharmacist. Pharmacists on a day-to-day basis can either save every patient and give the patient the opportunity to live normal healthy life, or on the other be the reason the patient has suffered an agonizing death. Unfortunately, with such power it is not uncommon that due to human-error, technological error, and even patient error for these errors to lead to death.
In 2012, the case regarding a patient named Margaret Link was negatively impacted from human-error. Margaret Link was given the wrong prescription for six months. These events
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Unfortunately, Link was too far into the medication to turn back from the hostile side effects of the medicine. Once the mistake was caught, the medication had already taken a role in Margaret Link’s health and her body had grown accustomed to the drug. Towards the end, Link’s body began to have periodic episodes of seizures if she did not take the medication, which ended up with her physicians having to prescribe her Ativan until they could wean her body off of it. This mistake was finally caught when someone behind the counter asked Link about her nerve pills which then lead to Link to realize why she has been developing such bizarre behaviors.
By the end, the pharmacist in this case was never named nor was the punishment for their action ever stated, yet similar cases within the area were noted with punishments. A case in April 2010 involved a pharmacist dispensing 360 tablets of methadone, while the correct order only stated for 120 tablets of morphine sulfate. This caused subsequent harm to the patient, leading the pharmacist to be punished with a $250 fine and was ordered by law to complete five hours of continuing
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Any individuals should immediately contact the physician in order to elucidate the issue, with that being said many may believe they will lose respect from their peers or not seen as being smart enough because they cannot read regular prescriptions. This is an issue physicians need to get out of their mindset. Pharmacists have every right to be in suspicion of the physicians’ orders as well, but they need to speak up in order for safer care to take place. In order to avoid any occurrence of this incidence physicians should build relationships with local doctors and get themselves more familiar with individual prescriptions and patient records. However, this stubbornness can become problematic if a physician takes the same knowledge into their practice, while having multiple patients who are relying on their knowledge to help
Statistics show that between 1979 and 2006, there were more than sixty two million deaths investigated and of those, 244,388 were caused by a hospital medication error (Cox, 2010). The following information highlights medication errors made in three facilities in the United States with the drug Heparin. The focus of this paper will be on how the medication errors were made, what could have prevented them, the legal ramifications from the mistakes, and changes that were implemented to eliminate potential future risks.
Medical error occurs more than most people realize and when a doctor is found negligent the patient has the right to sue for compensation of their losses. Debates and issues arise when malpractice lawsuits are claimed. If a patient is filing for a medical malpractice case, the l...
... for every pharmacist. This ratio dictates that pharmacists can not oversee every aspect of technicians’ jobs. It is this singular fact that very few people realize. The pharmacy technician who receives no formal training is responsible for not just the delivery of a patient’s medication, but also for their bill, their confidential information, and their life. The question now is, how can an uneducated individual be given so much responsibility? Technicians are granted these responsibilities because a pharmacist can not do the job alone. Pharmacists strive to mold each new technician into an employee that will realize what technicians really do. Pharmacists and technicians provide patients with safe and accurate medication in a timely manner. This is not a task for pharmacists or technicians alone; it is task that requires both personnel in order to be accomplished.
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.
I pleased to apply to the PharmD program as the program is one area that corresponds to my career dreams. Being part of this program gives one the opportunity to gain an excellent experience in working and collaborating with various health care providers in the ward. But more importantly, it facilitates a practical environment in dealing more closely with patients. Hence, it helps to provide the ultimate health care services to patients. Also, it permits me to carry on gaining different knowledge, skills, and values in addition to those I have already developed during my undergraduate studies. My interest in being a clinical pharmacist was first aroused during my SPEP rotation in the hospital setting where I was really impressed with the role of clinical pharmacists who provide a consistent process of patient care with healthcare teams to maintain the appropriateness, effectiveness and safety of the medication use. Unlike a pharmacist, a clinical pharmacist has a more diversified responsibilities and closeness to direct patient care. Moreover, provides
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
To many people all a pharmacist does is count pills or dispense medication. But the profession of pharmacy has moved tremendously beyond just dispensing medications to providing more patient oriented services. Pharmacists think it is time for a change and are coming together to fight for what many believe should already be considered a responsibility of a pharmacist. As healthcare professionals many pharmacists are not recognized as health care providers and consequently are limited in scope of practice, as well as compensation.1 However, this is not a universal or federal responsibility.1
- 29 studies found slips and lapses as common causes of error (Keers et al., 2013). Misidentification of medication or a patient are the most frequent and misreading a medication label/ product, prescription or other documentation are also common.
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.
According to Pharmacists, a pharmacist is “a person who distributes drugs that have been prescribed by a medical practitioner to patients”, but in reality they do so much more. Pharmacists are people who specialize in medicines (Pharmacists). They specialize in medicine to help treat patients with different illnesses and problems (Pharmacists). They help patients better understand the use of their medication (Pharmacists). They understand the composition, properties, and uses of medicines to determine which medication is needed for each patient’s problem or illness (Pharmacists).
However, most of the methods suggested by different studies and programs have failed due to various reasons (Chasin, 2011). In addition, the Institute of Medicine has shown that “on average, hospitalized patients are subject to at least one medication error per day (Radley, et.al. 2013, pg. 2).” When the number is totaled up, it becomes a serious case as it amounts to a large number of cases annually. In 2013, James the president of the Joint Commission indicated that there are 400,000 deaths annually and they are related to medical errors which can be
Pharmacists have a duty to promote their profession to health care professionals, patients, and the public. Although there are many ways to do so, the best is to be model practitioners of pharmacy and show everyone firsthand what pharmacists are really about. This must be done by setting the image of pharmacists being not just dispensing machines, but patient-centered care providers whose utmost priority is to give patients and prescribers useful drug information in order to play a part in achieving optimal life outcomes for the patient. Pharmacists must prove themselves to be accessible, effective, trustworthy, and indispensable.
First, here is some important background information about Pharmacists. A Pharmacist is someone who is trained and licensed to distribute medicinal drugs and to advise on their use. According to the Occupational Outlook Handbook Pharmacists do all of the following: "Fill prescriptions, verify proper amounts of medication to give to patients, check whether the prescription will interact negatively with other drugs that a patient is taking or conditions the patient has, instruct patients on how to and when to take a prescribed medicine, Advise patients on potential side effects they may experience from taking the medicine, Advise patients about general health topics, such as diet, exercise, managing stress, and on other issues, such as what equipment or supplies would be best for a health problem, Keep records and do other administrative tasks, Complete insurance forms and work with insurance companies to be sure that patients get the medicine they need, Teach other healthcare practitioners about proper medication therapies for patients, and lastly oversee the work of pharmacy technicians and pharmacists training."() Some pharmacists participate in compounding, where they create medications by mixing ingredients themselves. Pharmacists tha...
Listening to your Patient's Concerns about his or her Ability to Follow the Regimen. Nurses can recognize concerns of patients, such as cost of their medications or confusion about the similarities in color of their medications, the names of the medications which are not easy to remember, and the timing of dosage. The nurse will then help the patient seek support in that area of concerns raised by encouraging the patients to call their
Pharmacists often work together in a team with other healthcare professional like physicians and nurses. In the process, pharmacists will give advice to them on the selection of medication, by providing the evidences based on the dosage form, the side effects and possible interaction with food of the medication. On the other hand, pharmacists also take part in research and clinical studies. Recently, pharmacists are recruited to conduct pharmacy-based research in pharmacies. (Swanson, 2005)