AUDIT OUTLINE
1. AUDIT TOPIC
The explicit documentation being audited is the NSW Government Health Medication Chart (MR71) known as the adult National Inpatient Medication Chart (NIMC). The adult NIMC was introduced to support the standardization of medication legislation with respect to storage, administration and documentation of medications and safeguard patients against prescription errors and ensure privacy of information (Atik, 2013). According to the Australian Commission on Safety and Quality in Health Care (ACSQHC), 2012), the NIMC is useful in verifying patients susceptible to adverse drug reactions (ADR’s) and allergies as well as identifying medications by their generic name and intended use as well as clearly displaying the printed
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Most importantly the adult NIMC is used to establish the ‘five rights’ of the individual being first and fore mostly the right patient, right dose, right medication, right route and right time (Parker, Kucia, Fedoruk, Laws & Phillips, 2012). The audit tool employed to determine performance indication levels below 100% for the fore mentioned parameters will be the Medication Audit Chart (MAC) tool. The audit will focus on the relevance of correct medication documentation to the adult NIMC to ensure patients are provided with a quality of care that ensures safety and efficacy as well as supporting partnerships between health professionals and their patients to maintain person-centered care in relation to the administration of medications (National Inpatient Medication Chart 2014 National Audit Report, (NIMC National Audit Report), 2015). The audit will also include reviewing the correct use of abbreviations, that target INR for Warfarin is acknowledge by 2 registered nurses as well as their presence being required for the preparation and administration of all S4 and S8 medications including injectables. The audit data was collected from five adult patients recovering on an orthopaedic …show more content…
Continuity of Medication Management
Sub-Standard:
4.12 Patients, their carers, and clinicians are provided with a comprehensive medication list during handover and transfer of care and when medications are updated
Identifying patients and their current medications occurs when documentation in the NIMC is accurately completed and also allows for correct handover of patient information to ensure patient safety at the end of care (ACSQHC, 2012).
STANDARD 5: PATIENT IDENTIFICATION AND PROCEDURE MATCHING
Identification of Individual Patients
Sub-Standard:
5.1 It is essential that there are three approved identifiers for the recognition of patients to prevent medication errors occurring. This includes identifying the intended regimen and that the meticulous compliance of medication administration is adhered to by carers and other healthcare workers involved with the patients care. The application of accurately documenting patient information and medication administration into the adult NIMC is directly related to patient safety (ACSQHC,
Identifying patients correctly when providing Care: Nurses are supposed to have two resident Identifiers when trying to care for a patient for the first time and after that, one identifier is acceptable. Identifiers such as Room number or location are not acceptable. To ensure this is carried out correctly nurses must ask for two identifiers in situations such as specimen collection, when providing treatments or when collecting blood for clinical testing (containers must be labeled in front of the patient). The Purpose of this guideline is to ensure that the patients are been properly identified and that they are receiving the right treatments and medications (The Joint Commission, 2012).
I am truly amazed by the positive impact of bar-code medication administration (BCMA). Since we have a fully integrated electronic health record, it is a true closed loop-system, with medication order entry, pharmacy validation of medications, and clinical decision support. Implementing technology such as BCMA is an efficient way to improve positive identification of both the patient and medication prior to administration. It is estimated that the bar-code medication charting can reduce medication errors by 58% (Jones & Treiber, 2010). Even though we have good adoption of BCMA, nurses still make drug administration errors. In many of the cases, errors are caused by nurses, because they do not validate and verify. The integration of technology
According to Truitt et al. (2016) the study broke their examination up into the different phases of medication administration- prescribing or writing a medication order, transcription of the medication into the MAR, dispensing by the pharmacy, administration of the medication, and further monitoring after the administration. According to Truitt et al. (2016) about one-third of adverse drug events occur in the initial prescription phase and another one-third occurs during the administration phase. The one system, called the electronic medication administration record, is beneficial in cutting down the errors that occur in the transcription phase between the nurses and the pharmacy. According to Truitt et al. (2016) implementation of barcode medication administration record and the electronic medication administration record has reduced the amount of errors by 50% and serious errors by 25%. Truitt et al. (2016) also supports that it improves documentation, billing, and public
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
According to Accuracy at Every Step: The Challenge of Medication Reconciliation (n.d.), the most challenge is called medication reconciliation, which is a formal steps of gathering information related to the patient’s medication with accurate current medication list and compared to the doctor’s admission, transfer and discharge orders. Its aim is to prevent medication errors. There are three steps process- Verification (gather medication history), Clarification (confirm the medication with doses, properly) and Reconciliation (documenting with medication information). This challenge is important to obtain accurate information on all patients entering the hospital. Information technology may play an important role in improving
Many medication errors occur due to abbreviated words symbols, and dosage that cant be read and become misunderstood. These mistakes can cause harm if no one notices it. Many patients end up with a life threatening problem due to a medical error. A nurse might give the patient the wrong dose because of the handwritten abbreviation the doctor wrote is not clear. Many abbreviations are similar and this can cause complication. If abbreviations are similar the best thing to do is write the abbreviation completely out and always ask if not sure. Providing unabbreviated prescriptions, communication, and writing all abbreviations out can reduce errors in the healthcare setting. Another consideration would be to make sure in the healthcare setting written policies are mentioned and used.
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.
Polypharmacy among the elderly is a growing concern in U.S. healthcare system. Patients who have comorbities and take multiple medications are at a higher risk for potential adverse drug reactions. There is a great need for nursing interventions in conducting a patient medication review also known as “brown bag”. As nurses obtain history data from patients at a provider visit, the nurse should ask “what medications are you taking?” and the answer needs to include over-the-counter medications as well. If the response does not include any medications other than prescribed meds, it is incumbent upon the nursing professionals to question the patient further to ensure that no over-the-counter medications or supplements are being consumed. This is also an opportunity for the nurse to question about any adverse reactions the patient may be experiencing resulting from medications. Polypharmacy can result from patients having multiple prescribers and pharmacies, and patients continuing to take medications that have been discontinued by the physician. Nurses are in a unique position to provide early detection and intervention for potentially inappropriate medications and its associated adverse drug reactions.
The Medication Administration Accuracy Project is a quality improvement project, whose purpose is to improve the accuracy of nursing medication administration. The study used for this project was to find where the most common “wrong doings” happened in the medication process and how to get rid of it. After a year of this project the medication error percent went from 4.3% in 2010 to 1.2% in 2011. The Bar Code Administration System implementation had been very successful with a 95% success rate every year that it is done. The study provided important insight on reducing the medication errors in children. Some were: making sure there are no distractions as possible, double checking medications and making sure the dose in adequate range for the child, and making sure you have two ways of identification with the bar code scanning (Hardmeier, A., Tsourounis, C., Moore, M., Abbott, W., Guglielmo, J.
Responsibility and accountability become important when medical staff gives or doses patients with medication. The chance for making a medication error presents itself at all times. Those passing medications must follow established policies and procedures developed and laid forth by t...
Administration of medication is a vital part of the clinical nursing practice however in turn has great potential in producing medication errors (Athanasakis 2012). It has been reported that over 7,000 deaths have occur per year related to medications errors within the US (Flynn, Liang, Dickson, Xie, & Suh, 2012). A patient in the hospital may be exposed to at least one error a day that could have been prevented (Flynn, Liang, Dickson, Xie, & Suh, 2012). Working in a professional nursing practice setting, the primary goal is the nurse and staff places the patient first and provides the upmost quality care with significance on safety. There are several different types of technology that can be used to improve the medication process and will aid staff in reaching a higher level of care involving patient safety. One tool that can and should be utilized in preventing medication errors is barcode technology. The purpose of this paper is to demonstrate how implementing technology can aid patient safety during the medication administration process.
Nurse’s should have a strong pharmaceutical knowledge background and be aware of the potential harm a medication could cause. In the process of medication administration, registered nurses are responsible to “determine that each medication order is clear, accurate, current and complete”. Medications should be withheld when a medication order is incomplete, illegible, ambiguous or inappropriate; with concerns being clarified with the prescriber (CNO, 2015)”. The critical care nurse demonstrated ineffective communication, which was shown by failing to ask the physician for clarification. Another instance of miscommunication is during medication reconciliation, which is a formal process in which healthcare providers work together to ensure that patient medication information is communicated consistently and accurately across transitions of care (Etchells, 2012).
while transferring patients between units. [After reviewing these events], “The Joint Commission identified “Improve the Safety of Using Medications” as one of the 2009 National Patient Safety Goals (Cleveland Clinic, 2009, p.1). In relation to this safety goal, hospitals created a medication reconciliation form that resides in the patient’s ch...
For many patients the scariest part of being in the hospital is having to rely on other people to control their life changing decisions. There are multiple causes of patient harm, one of the major contributors are medication errors made by health care professional. Medication errors are inappropriate dispensing and administration of drugs which cause harmful effects such liver damage and excessive bleeding. Most cases of medication errors in hospitals occur as a result of wrong diagnosis by the doctors leading administration of inappropriate drug, poor communication between doctors and nurses and between patients and nurses who issue the drugs. However in an article by the International Journal of Nursing practice, in Australia many occurrences
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.