Patient Safety Incident: A look at the Nurses role in paediatric medication errors and prevention
There are many different patient safety issues prevalent in the clinical setting today. This essay will take a particular focus on medication errors in the paediatric population which can lead to poor clinical outcomes for such patients. This is a substantial problem because according to Hughes and Edgerton (2005), it accounts for the most common harm to paediatric patients during treatment. The essay will deal with the role of the nurse in facilitating such incidents. Therefore there will be a specific focus on the extent of errors at stages of medication administration, education and monitoring. The essay will then conclude with a critical
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WHO,( 2005, p8) defines it as “an injury related to medical management, in contrast to complications of disease”. Children are at a much higher risk of developing an adverse event as a consequence of a medication error due to their limited physiological development and communication (Hughes and Edgerton (2005)). Sandlin (2008) refers to a quote by Stu Levine, PharmD, of the Institute for Safe Medication Practices, who declares that adverse drug events occur at three times a higher rate in paediatrics as supposed to adults.
Following on, this highlights the importance of the nurse’s role in preventing medical errors. If the incident is recognised before the problem occurs it eradicates the risk of an adverse event occurring in a patient. Nurses are usually the last barrier in the potential for a medication error to cause a problem in a child. Hughes and Edgerton (2005) refer to a study which states the majority of healthcare workers, including nurses themselves, view patient safety primarily as their
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They are responsible for identifying possible toxic or adverse events associated with the effectiveness of the drug. Failure to do so is regarded as a medical error. Careful monitoring is vital, specifically in the case of paediatric patients as their communication skills are limited. (Hughes and Edgerton (2005)). Young kids are vulnerable as they cannot tell if a problem is wrong and aren’t able to tell nurses if they don’t feel ok (Sandlin, (2008)). WHO (2007) guidelines also state that the monitoring of medication in children is of utmost importance. This is due to the fact that very small numbers of clinical trials are carried out on children. This establishes for the use of “off label” drugs. Extra vigilance is required in these
Humans, throughout recorded history, have searched for a proper way of living which would lead them to ultimate happiness; the Nicomachean Ethics, a compilation of lecture notes on the subject written by Greek philosopher Aristotle, is one of the most celebrated philosophical works dedicated to this study of the way. As he describes it, happiness can only be achieved by acting in conformity with virtues, virtues being established by a particular culture’s ideal person operating at their top capacity. In our current society the duplicity of standards in relation to virtue makes it difficult for anyone to attain. To discover true happiness, man must first discover himself.
Medication errors in children alone are alarming, but throw an ambulatory care setting into the mix and it spells disaster. When it comes to children and medication in the ambulatory care setting, the dosage range is drastically out of range compared to those that are treated in the hospital setting (Hoyle, J., Davis, A., Putman, K., Trytko, J., Fales, W. , 2011). Children are at a greater risk for dosage errors because each medication has to be calculated individually, and this can lead to more human error. The errors that are occurring are due to lack of training, dosage calculation errors, and lack of safety systems. Medication errors in children who are receiving ambulatory care can avoided by ensuring correct dosage calculation, more in-depth training of personal and safety systems in place.
Unver, V., Tastan, S., & Akbayrak, N. (2012). Medication errors: Perspectives of newly graduated and experienced nurses. International Journal Of Nursing Practice, 18(4), 317-324. doi:10.1111/j.1440-172X.2012.02052.x
The most common kind of medication error is administering the wrong medication or giving wrong doses. A medication error is any error that happens to patients whether they suffer any harmful results or not. Inappropriate nurses-to-patients ratio should be taken into consideration because it can cause medication errors. A new study shows that every year about 210,000-400,000 people who were admitted to the hospital die due to medication error; it also shows that is is “the third leading cause of death behind heart disease and cancer”(MacDonald). For instance, an interview was done with Nurse Carol, a retired nurse; she said that she made a medication error while administering medication to one of her patients. She said that she was rushing and accidentally gave Cozaar to one of her patients instead of Colace. Cozaar is often used for high blood pressure and Colace is for constipation. She said her patient’s pressure dropped very low after taking the medication; she realized then that she gave the patient the wrong medication. Nurse Carol also said that if she did no...
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.
Through this opportunity, I have become aware of legal, ethical and professional regulations of the nurse prescribing. I have gained a comprehensive knowledge of pharmacology, especially on the medications to achieve the competencies essential for a successful nurse prescriber. The development process has enlightened me with the gravity of my new role, and the accountability and responsibility which accompanies it. Through the innovation of the nurse prescribing process, the professional boundaries of nurses are being redefined for the benefit of both patient and nurse. The structured reflective practice has the potential to develop staff and improve the implementation of professional standards. Reflection can help to make sense of complicated and difficult situations, as well as learn from the experiences. Thus, a healthcare staff can identify educational needs, workload stressors, highlight barriers to development and provide evidence of continuing professional development. In addition, staff could become increasingly more motivated to empower performance and patient care. Healthcare providers have an ethical obligation to inform patients about their on-going plan of care, including if a medical error has occurred. Current thinking in nursing advocates the need for education in the ways of autonomy, critical thinking, and sensitivity to others. Good communication encourages collaboration and helps prevent medication errors. Many potential and actual medical errors fall within the sphere of nursing practice. Thus, nurses have an ethical obligation to help prevent and manage medical
A medication error is any preventable event that may cause or lead to inappropriate medication use or harm to a patient (NCCMERP 2014). The death rate for medication errors averages around 7,000 deaths per year. Lawsuits for medication errors were mainly made against registered nurses because nurses are the last people to check a medication before it is administered. 426 medication error related lawsuits were made against registered nurses. (RightDiagnosis 2014).
Agyemang, REO, and A While. "Medication errors: types, causes and impact on nursing practice." British Journal of Nursing (BJN) 19.6 (2010): 380-385. CINAHL Plus with Full Text. EBSCO. Web. 7 Mar. 2011.
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.
Ethical dilemmas are the issues that nurses have to encounter everyday regardless of where their workplaces are. These problems significantly impact both health care providers and patients. Patient safety is the most priority in nursing and it can be jeopardized by a slight mistake. Medication errors and reporting medication errors have been major problems in health care. Errors with medications have been found to be the most common cause of adverse drug effects (Brady, Malone, Fleming, 2009). Northwestern Memorial Hospital in Chicago conducted a research in 2012 that approximately forty percent of the hospitalized clients have encountered a medication error (Lahue et al., 2012). A nurse’s role is to identify and report these medication errors immediately in order to stop or minimize any possible harm to the patients. Ethical moral dilemmas arise when reporting the mistakes that have been made by one’s own colleagues, acquaintances, peers, or physicians.
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)”.
Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.
O’Shea, E (1999) Factors contributing to medication errors: a literature review. Journal of Clinical Nursing. 8, 5,496-503.
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.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).